reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  59A-2-9.8
				  NMSA 1978, Section
				  59A-15-20
				  NMSA 1978; Sections 59A-22B-1 through 59A-22B-5 NMSA 1978; and Sections
				  59A-57-1 through
				  59A-57-11 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Terms used in these rules are as defined in Section
				  59A-22B-2 NMSA 1978, and in 13.10.29 NMAC, except as supplemented and
				  superseded below.
A.
"Benefit"
means any medical service, medical service location,
				medical provider selection, pharmaceutical, or medical supply that is the
				subject of a prior authorization request.
B.
"Utilization review
				organization"
or "URO" means an entity engaged by a carrier to determine
				medical necessity for covered services. A URO includes a pharmacy benefits
				manager ("PBM") who determines medical necessity for a carrier's prescription
				drug coverage.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.8 - GENERAL REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier shall comply with the standard prior authorization
				  processes specified in these rules.
A.
Responsibility for requesting prior authorization.
(1) A carrier shall accept a prior
				authorization request submitted by a provider or by a covered person.
(2) If a covered person directly submits, or
				attempts to submit, a prior authorization request, the carrier shall provide
				the covered person all assistance required to properly submit the request,
				including assistance with obtaining required documentation and information to
				meet clinical guidelines.
(3) A
				carrier shall prohibit its participating providers from billing a covered
				person for a delivered benefit for which prior authorization was required if
				the provider failed to obtain the required authorization without the covered
				person's informed and documented consent.
(4) A carrier shall allow non-participating
				providers to:
(a) request prior authorizations
				and submit supporting documentation by all submission methods authorized by
				these rules; and
(b) receive
				confirmations and tracking numbers as required by these rules.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.9 - PRIOR AUTHORIZATION SUBMISSION

Current through Register Vol. 35, No. 13, July 16, 2024
A. A carrier shall:
(1) accept prior authorization requests
				submitted at any time prior to the delivery of service;
(2) accept prior authorization requests
				telephonically and by facsimile;
(3) offer at least one bi-directional
				electronic prior authorization portal;
(4) allow a provider to upload in a secure
				manner the supporting documentation associated with an electronic prior
				authorization request, subject to reasonable limits on file type and
				size;
(5) accept and consider any
				information from a provider that will assist in the review;
(6) require only the information necessary to
				evaluate the request;
(7) not
				reject a request solely on the basis of documentation or submission errors that
				do not prevent substantive review;
(8) ensure that the system it operates for
				receiving electronic prior authorization requests and supporting documentation
				satisfies all applicable Health Insurance Portability and Accountability Act
				("HIPAA") transaction requirements and operating rules no later than the
				effective date that such requirements and rules are established;
(9) make its system available for accepting
				electronic prior authorization requests and supporting documentation 24-hours
				per day, seven-days per week. Planned maintenance or down time of the system
				shall be performed during historically low-utilization periods; and
(10) notify providers of planned maintenance
				or downtime of the system at least 24-hours in advance. A carrier shall notify
				providers of any unplanned system downtime as soon as practicable.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.10 - DOCUMENTATION AND TRANSPARENCY

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Prior authorization forms.
(1) A
				carrier shall accept the uniform prior authorization request form(s) developed
				by the superintendent and found on the superintendent's website at
www.osi.state.nm.us
.
(2) A carrier may ask the superintendent to
				approve a non-uniform prior authorization request form. If the superintendent
				approves the non-uniform request form, the carrier shall prominently publish
				the form to providers on its website.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.11 - AUTO-ADJUDICATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. No later than
				January 1, 2022, a carrier shall implement a process to auto-adjudicate
				electronically submitted prior authorization requests.
(1) A carrier shall comply with all statutory
				timelines applicable to prior authorization review. A list of all statutory
				prior authorization review timelines is posted on the OSI website.
(2) A carrier may reject for correction an
				auto-adjudicated prior authorization request for reasons other than medical
				necessity as long as the rejection is completed within statutory
				timelines.
(3) A carrier may pend
				an auto-adjudicated prior authorization request if it requires manual review,
				as long as the review is completed within statutory timelines.
(4) A carrier shall not automatically deny an
				auto-adjudicated prior authorization request. A carrier shall only deny a prior
				authorization request based on a live review.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.12 - EVALUATION OF PRIOR AUTHORIZATION POLICY AND PROVIDER PERFORMANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This section of the rule shall only apply to
				fully-insured commercial coverages regulated by the superintendent.
B.
Review of covered benefits that
				require prior authorizations.
Annually, beginning in 2023, a carrier
				shall review its prior authorization requirements for all covered benefits,
				except for inpatient admissions to acute-care hospitals, including transfers,
				in order to assess the continued utility of each requirement.
(1) At a minimum, a carrier's assessment
				shall consider the following elements:
(a)
				the approval rate for each covered benefit for which a prior authorization was
				required;
(b) whether, based on
				demonstrable evidence, including claims and clinical data, the prior
				authorization requirement for each covered benefit protects patient safety or
				generates better health outcomes, or both;
(c) whether, based on demonstrable evidence,
				including claims and clinical data, the prior authorization requirement for
				each covered benefit prevents the need for higher cost services;
(d) whether based on demonstrable evidence,
				including claims and clinical data, the prior authorization requirement of each
				covered benefit has deterred any reasonable suspicion of insurance fraud,
				waste, or abuse;
(e) whether, based
				on demonstrable evidence, including claims, clinical and operational data, and
				considering both the providers' and the carrier's experience, the costs and
				other administrative burdens associated with the prior authorization
				requirement for a covered benefit outweigh the demonstrated benefits of the
				requirement; and
(f) whether the
				prior authorization requirement for a covered benefit, based on demonstrable
				evidence including provider and member grievances, appeals and complaints, and
				claims and clinical data, contributed to unreasonable or unnecessary delays in
				treatment or adverse health outcomes for a covered person.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.13 - 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 violation of this rule may be imposed against an
				  insurer in accordance with Sections
				  59A-1-18 and
				  59A-46-25
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.14 - 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 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This rule applies to every insurer who issues an
				individual or group health insurance policy, health care plan or certificate of
				health insurance that provides a prescription drug benefit for a resident of
				this state. Herein, each such insurer is referred to as "Insurer."
B.
Exceptions.
This rule does
				not apply to:
(1) An excepted benefits plan
				as defined in Section
				59A-23G-2 NMSA
				1978.
(2) Medicare supplemental
				health insurance as defined by Section 1882(g)(1) of the Federal Social
				Security Act; or
(3) Any coverage
				supplemental to the coverage provided pursuant to Chapter 55 of Title 10 United
				States Code Annotated and similar supplemental coverage provided to coverage
				pursuant to a group health plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-22-42,
				  59A-23.7.14, 59A-46-44 and 59A-47-45.5 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Unless
				inconsistent with a term defined in this rule, or the usage of a term in this
				rule, the definitions in 13.10.29 NMAC apply.
B.
"provider"
means, in addition
				to the definition in Paragraph (13) of Subsection P of
				13.10.29.7
				NMAC, pharmacists authorized to prescribe hormonal contraception directly to
				patients pursuant to
				16.19.26.14
				NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.8 - COVERAGE REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Oral contraceptives.
An insurer satisfies its obligation to cover
				a sufficient number and assortment of oral contraceptives to reflect the
				variety of oral contraceptives approved by the federal food and drug
				administration only if its plan covers contraceptive pills of differing hormone
				combinations at differing strengths that reflect the variety of unique
				combinations approved by the federal food and drug administration.
B.
Immediate Post-Partum Long Acting
				Reversible Contraception.
Included in the description of clinical
				services covered by this rule is immediate (pre-discharge) post-partum long
				acting reversible contraception.
C.
Six-Month Dispensing.
An insurer shall provide coverage and shall
				reimburse a health care provider or dispensing entity on a per unit basis for
				dispensing a six-month supply of contraceptives, provided that the
				contraceptives are prescribed and self-administered. Nothing in this rule shall
				be construed to require a health care provider to prescribe six months of
				contraceptives at one time or permit an insurer to limit coverage or impose
				cost sharing for an alternate method of contraception if an insured changes
				contraceptive methods before exhausting a previously dispensed
				supply.
D.
Coverage for
				Prescription Contraceptive Drugs and Devices.
An insured, an insured 's
				designee, or an insured's health care provider may submit a request to an
				insurer for coverage of a non­covered contraceptive drug or device
				pursuant to Subsections C and D of Section
				59A-22-42
				NMSA 1978. Such request shall indicate whether the covered contraceptive drug
				or device is not available or is medically necessary for the insured. An
				insurer may require that the request for coverage be in writing. If the
				insured' s health care provider determines that the use of a non-covered drug
				or device is medically necessary, the health care provider's determination
				shall be final.
E.
Sexually
				transmitted infections
. An insurer is obligated to provide
				contraceptives for the prevention of sexually transmitted infections.
F.
Confidentiality of services.
An insurer shall maintain confidentiality of claims and services pursuant to
				state and federal law, including the Domestic Abuse Insurance Protection Act,
				Sections
				59A-16B-1 et seq.
				NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.9 - PROVIDER ACCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Access.
If an insurer's plan limits coverage of contraceptive
				services and supplies to in-network providers, the Insurer shall establish and
				maintain a network for these services and supplies that meets the access and
				adequacy standards set forth in state and federal network adequacy
				law.
B.
Limited access
				requirements
. If an insurer's plan network lacks a sufficient number or
				type of participating providers or facilities to provide a particular covered
				contraceptive service or supply in a timely manner appropriate for the covered
				person's condition, the insurer shall allow the covered person to obtain the
				covered service or supply from a provider or facility within reasonable
				proximity of the covered person at no greater cost than if the service or
				supply were obtained from in-network providers and facilities.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.10 - COVERAGE FOR CONTRACEPTION WHERE A PRESCRIPTION IS NOT REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
A. If a
				prescription is not required for the purchase of a contraceptive, an insurer
				shall not charge a member for a purchase at an in-network pharmacy, and shall
				provide a process for the member to obtain reimbursement for an out-of-network
				purchase.
B. An insurer's website
				and evidence of coverage handbook shall clearly explain the process a covered
				person shall use to submit a claim for reimbursement for the purchase of
				non-prescription contraception drugs or devices. The reimbursement process is
				subject to these requirements:
(1) An insurer
				shall allow a covered person at least 90 days from the date of purchase to
				submit a request for reimbursement.
(2) An insurer shall reimburse a covered
				person within 30 days of receipt of a timely and complete reimbursement request
				submitted electronically, by email, or by fax, and within 45 days of receipt of
				a timely and complete reimbursement request submitted by U.S. mail.
(a) A reimbursement request that is
				transmitted electronically, via email, or fax, pursuant to the insurer's
				instructions, is deemed received by the insurer on the date of receipt, unless
				the covered person receives notice of a transmission error.
(b) A request for reimbursement is complete
				if it contains the covered person's name and address, their plan identification
				number, and a paid receipt explicitly delineating the purchased services or
				supplies.
(c) An insurer may
				require a covered person to use a specific claim form for a reimbursement
				request.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.11 - COVERAGE DISPUTES

Current through Register Vol. 35, No. 13, July 16, 2024
A dispute between an insurer and a covered person concerning
				  a request to grant coverage for a contraceptive supply or service shall be
				  processed in accordance with Sections
				  59A-23-12.1,
				  59A-47-47.1,
				  59A-22B-5,
				  59A-22-42,
				  or
				  59A-46-52
				  NMSA 1978, as applicable, or 13.10.17 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.12 - TRANSPARENCY OF COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Forms.
An insurer shall provide each covered person with a
				contraceptive coverage summary that clearly explains the scope of contraceptive
				coverage and how to access this benefit at least annually. The coverage summary
				through written materials or links to an insurer's website and a toll free
				number must include the following information:
(1) whether covered services or supplies are
				available from in-network and out-of-network providers;
(2) whether there are any limitations on
				contraceptive services or supplies;
(3) that the coverage required shall not be
				subject to:
(a) cost sharing for
				insureds;
(b) utilization
				review;
(c) prior authorization or
				step-therapy requirements; or
(d)
				any other restrictions or delays on the coverage;
(4) if elected by the insurer, that
				brand-name pharmacy drugs or items are subject to cost sharing when at least
				one generic or therapeutic equivalent is covered within the same method of
				contraception without patient cost sharing, unless the insured's health care
				provider determines that a particular drug or item is medically
				necessary;
(5) that coverage will
				be provided for a six-month supply of prescribed and self-administered
				contraceptives;
(6) a list of the
				covered contraceptive drugs and devices, as well as clinical services, that are
				covered without cost-sharing;
(7) a
				description of the process and forms required to address coverage disputes in
				Sections 59A23-12.1, 59A-47-47.1, 59A-22B-5, 59A-22-42, or 59A-46-52 NMSA 1978,
				as applicable, or 13.10.17 NMAC; and
(8) a description of the process and forms
				related to coverage for contraception where a prescription is not
				required.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.13 - NONDISCRIMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
An Insurer who is legally obligated to provide contraceptive
				  supplies or services shall do so without discriminating against the covered
				  person on the basis of race, color, national origin, sex, sexual orientation,
				  gender expression or identity, marital status, age, citizenship, immigration
				  status, or disability. This includes, but is not limited to, providing coverage
				  for of any method of over-the-counter contraception without regard to the sex,
				  or gender identity or expression, of the covered person.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.14 - RULES FOR HSA QUALIFYING PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
An insurer who issues a health benefit plan that qualifies as
				  a health savings account ("HSA-qualifying plan") is subject to this rule. A
				  deductible under an HSA-qualifying plan for over-the-the counter contraceptive
				  supplies or services and voluntary male sterilization shall not exceed the
				  minimum amount required to preserve the covered person's ability to claim tax
				  exempt contribution and withdrawals from the covered person's health
				  savings.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.15 - 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 violation of this rule may be imposed against an
				  insurer in accordance with Sections
				  59A-1-18 and
				  59A-46-25
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 32 - COVERAGE FOR CONTRACEPTION › Section 13.10.32.16 - 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 33 - SURPRISE BILLING › Section 13.10.33.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules apply to every health insurance carrier
				  ("carrier") that provides health coverage under a policy, arrangement, contract
				  or plandescribed in Section
				  59A-57A-12 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  59A-2-9
				  NMSA 1978, Sections
				  59A-57A-1 through
				  59A-57A-13
				  NMSA 1978 and Section
				  59A-16-21.3
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For definitions of terms contained in this rule, refer to
				  Section
				  59A-57A-2 NMSA 1978
				  and 13.10.29 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.8 - REFUNDS FOR OVERPAYMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Notice of payment and right to a refund
. A carrier who reimburses
				a provider for a surprise bill shall provide the covered person an explanation
				of benefits ("EOB") showing, at a minimum, the name of the provider, the date
				of service, the amount billed and the amount paid. As of June 1, 2021, the
				first page of the EOB shall provide a surprise billing explanation of benefits
				and rights and contain the following statement in bold and of at least 12 point
				type:
SURPRISE BILLING - YOU RECENTLY VISITED A PROVIDER WHO IS NOT
				  IN YOUR PLAN'S NETWORK. IF YOU HAVE ALREADY PAID THE PROVIDER MORE THAN YOU
				  OWE, THE PROVIDER OWES YOU A REFUND WITHIN 45 DAYS OF THE DATE THE PROVIDER
				  RECEIVED OUR PAYMENT. IF YOU DO NOT RECEIVE A REFUND WITHIN THAT 45-DAY PERIOD,
				  YOU MAY FILE AN APPEAL WITHIN 180 DAYS AFTER EXPIRATION OF THE 45-DAY PERIOD AT
				  WWW.OSI.STATE.NM.US OR 1-855-427-5674.
B.
Issuance of the EOB.
A
				carrier shall issue the EOB within 15 days of the payment.
C.
Payment notice to provider.
A
				carrier who reimburses a surprise bill shall inform the out-of-network provider
				of the in-network cost-sharing amount owed by the covered person. Any notice of
				the covered person's cost-sharing responsibility shall refer to New Mexico's
				surprise billing protections act and the provider rights granted
				therein.
D.
Appeal
				process
. A covered person may appeal a provider's failure to make a
				timely or complete refund of an excess payment using the surprise billing
				appeal form on OSI's website.
(1) The appeal
				must be filed within 180 days after the expiration of the 45-day period in
				which the provider was required to refund the covered person's excess
				payment.
(2) The provider shall
				have 30 days to respond to the appeal in writing.
(a) A provider's failure to timely respond
				shall result in an order from the superintendent directing the provider to pay
				the full amount of the claimed refund.
(b) If a provider timely responds to a refund
				appeal, the superintendent shall resolve the appeal following the rules that
				govern informal hearings. If the superintendent determines that a provider owed
				a refund, the superintendent shall order the provider to pay the refund amount
				with interest pursuant to Section
				59A-16-21.1
				NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.9 - COVERED PERSON RIGHTS

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier shall afford a covered person these rights:
A.
Out of state care.
A carrier
				shall reimburse a surprise medical bill as required by law regardless of the
				situs of delivery of the medical care, including medical care rendered
				out-of-state.
B.
Specific
				consent
. For purposes of Subparagraph (b) of Paragraph (1) of Subsection
				Y of Section
				59A-57A-2 NMSA 1978,
				"specific consent" shall only be valid if the covered person has a meaningful
				choice between a participating provider and a nonparticipating provider; the
				covered person was not encouraged or coerced by a network provider or the
				carrier into selecting the out-of-network provider; and the covered person
				signs a notice and disclosure statement, at least five days before the service
				or supply is received, acknowledging that the covered person may be liable for
				a balance bill and chooses to receive the service or supply.
C.
Notice of Rights.
A carrier
				shall provide each covered person with notice of surprise billing protection
				act rights in the plan's evidence of coverage and as directed by the
				superintendent in a bulletin.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.10 - PROVIDER CLAIM SUBMISSION

Current through Register Vol. 35, No. 13, July 16, 2024
An out-of-network provider shall not bill a covered person
				  for a potential surprise bill without first submitting the bill to the covered
				  person's designated carrier and obtaining a payment or
				  denial.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.11 - REPORTS REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier shall annually submit a surprise billing data
				  report using a template provided by the superintendent. The template shall
				  require a carrier to report changes to the percent of claims paid for emergency
				  services. The report shall be filed annually by May 1st of each year and shall
				  contain data from the full prior calendar year.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.12 - PROVIDER COMPLAINTS

Current through Register Vol. 35, No. 13, July 16, 2024
A provider may dispute the denial, or reimbursement amount,
				  of a surprise bill pursuant to the applicable procedures in 13.10.16
				  NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 33 - SURPRISE BILLING › Section 13.10.33.13 - 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 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Office of Superintendent of Insurance
				  ("OSI").
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This section identifies the excepted benefits and excepted
				  benefits products that are subject to this rule, and applicable exceptions.
A.
Subject products
This rule applies to these excepted benefits products:
(1) accident only;
(2) specified disease or illness;
(3) hospital indemnity;
(4) other fixed indemnity;
(5) disability income;
(6) supplemental; and
(7) insurance similar to workers'
				compensation (non-subject worker).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-18, 59A-16 and 59A-23G-3 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.4 - DURATION

Current through Register Vol. 35, No. 13, July 16, 2024
Permanent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to establish regulatory
				  requirements for the subject excepted benefit plans. The rule will standardize
				  and simplify the terms and coverages; facilitate public understanding and
				  comparison of coverage; eliminate provisions that may be misleading or
				  confusing in connection with the purchase and renewal of the coverages or with
				  the settlement of claims and require disclosures in the marketing and sale of
				  subject excepted benefit plans.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For definitions of terms contained in this rule, refer to
				  13.10.29 NMAC, unless otherwise noted below.
A.
"Accident only plan"
means an
				insurance agreement that conditions a fixed indemnity benefit on the occurrence
				of an injurious accident.
B.
"Certificate"
means a document that extends coverage under a group
				plan to a group member.
C.
"Direct response insurer"
means a carrier who does not sell its
				insurance products through producers.
D.
"Disability income plan"
means an insurance agreement that provides income protection benefits during a
				period of disability resulting from either sickness, pregnancy, injury or a
				combination of these.
E.
"Domestic co-insured"
means a spouse or domestic partner insured
				under the same plan or certificate.
F.
"Hospital indemnity plan"
means an insurance agreement that conditions a fixed indemnity benefit on the
				hospitalization, hospital-based treatment or hospice care of a covered
				person.
G.
"Occupational
				accident plan"
means an accident-only plan that pays a fixed indemnity
				benefit for injury that results from an occupational accident involving a
				covered subject worker.
H.
"Other fixed indemnity"
means a fixed cash benefit payable to a
				covered person on the occurrence of an event, circumstance or condition, other
				than or in addition to accident, injury, illness or disability.
I.
"Plan"
means any individual,
				group or blanket insurance subject to this rule provided through a standalone
				policy, certificate, contract or rider.
J.
"Non-contributory"
means that
				a covered person pays no premium, membership fee or dues to qualify for
				coverage or benefits under the plan.
K.
"Non-subject worker plan"
means an insurance agreement that provides benefits similar to workers'
				compensation benefits to a self-employed non-subject worker.
L.
"Specified disease plan"
means an insurance agreement that conditions a fixed indemnity benefit on the
				occurrence or diagnosis of a specific disease or illness that is either
				life-threatening or likely to cause a covered person to incur significant
				financial obligations.
M.
"Supplemental plan"
means an insurance agreement that provides
				benefits that supplement coverage under a group major medical, TRICARE or
				Champus plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.9 - ADDITIONAL REQUIREMENTS FOR DISABILITY INCOME PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A disability income plan is subject to these additional
				  requirements:
A.
Benefit
				reduction
A disability income plan may provide that benefits shall
				decrease by up to fifty percent if the covered person is or attains the age of
				62 during the period of disability.
B.
Disability limitation
A
				disability income plan shall only provide benefits for disability resulting
				from injury, sickness, pregnancy or combination of these causes.
C.
Partial disability
A
				disability income plan shall consider an individual to be partially disabled if
				the individual:
(1) is unable to perform one
				or more but not all of the substantial and material duties or words of similar
				import, of the individual's employment or existing occupation or work a
				specified percentage of time, or a specified number of hours, or earn a
				specified amount of compensation; and
(2) remains engaged in work for wage or
				profit.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.10 - ADDITIONAL REQUIREMENTS FOR ACCIDENT-ONLY PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
An accident-only plan is subject to these additional
				  requirements.
A.
Plan
				definitions
An accident-only plan:
(1)
				shall not define "accident" more narrowly than an injurious event during the
				coverage period that was unexpected and unintended from the standpoint of the
				covered person.
(2) shall not define
				"injury" more narrowly than physical or mental harm that results from an
				accident, no matter the degree of harm or when it
				manifests.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.11 - ADDITIONAL REQUIREMENTS FOR HOSPITAL INDEMNITY PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A hospital indemnity plan is subject to these additional
				  requirements.
A.
Benefit
				minimum
A hospital indemnity plan shall pay a minimum lump-sum of no
				less than $1,500 upon initial confinement. A plan may offer additional lump-sum
				or daily benefits for additional periods of confinement as defined by the plan,
				subject to the provisions contained in this rule.
B.
Continuous hospital
				confinement
A hospital indemnity plan shall treat consecutive days of
				in-hospital service received as an inpatient, and successive inpatient
				confinement for treatment of the same condition within 30 days of prior
				discharge, as a single period of confinement. A carrier shall not combine
				confinements that result from medically distinct causes. A plan may exclude
				benefits for any calendar day period of confinement that does not result in
				billed charges by a hospital.
C.
Basis of compensation
A hospital indemnity plan shall provide
				benefits only on a fixed indemnity basis.
D.
Hospital indemnity benefit
				limitations
A hospital indemnity plan shall only offer benefits
				conditioned on a covered person being hospitalized, or receiving hospice,
				convalescent or extended care, hospital-treatment related ambulatory surgical
				center services, ambulance service to or from a covered confinement,
				hospital-affiliated outpatient services, anesthesia, surgery, emergency care
				leading to a hospital, convalescent or hospice confinement, lost wages during a
				period of hospital confinement, or expenses to travel to or from a hospital
				confinement. These benefits shall not be offered as a separate rider.
E.
Confinement defined
A
				hospital indemnity plan shall define "confinement" as any consecutive 24-hour
				period during which medical observation or services are provided on a
				continuous basis in a licensed medical facility, each immediately successive
				such period, and any period of time less than 24-hours on the date of discharge
				from any such confinement.
F.
Convalescent or extended care
A plan that provides a benefit
				conditioned on a covered person receiving convalescent or extended care
				following hospitalization shall provide such benefits if the admission to the
				convalescent or extended care facility is within 14-days after discharge from
				the hospital.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.12 - OTHER FIXED INDEMNITY

Current through Register Vol. 35, No. 13, July 16, 2024
Other fixed indemnity benefits are subject to these
				  additional requirements.
A.
Benefits
Other fixed indemnity benefits shall be no less than $50
				per triggering event, circumstance or condition. The aggregate amount of all
				other fixed indemnity benefits offered shall not exceed $10,000.
B.
Limitations
A carrier shall
				not offer or sell a person a plan, or combination of plans, that provide more
				than ten other fixed indemnity benefits. A carrier shall not sell a plan that
				includes other fixed indemnity benefits if that would result in the customer
				having coverage for more than ten other fixed indemnity benefits under one or
				more plans. An application for a plan that offers other fixed indemnity
				benefits shall inquire whether a prospective insured has other excepted
				benefits coverage, and about the number and type of other fixed indemnity
				benefits covered by a prospective insured's other coverage, if any. A carrier
				that offers more than five other fixed indemnity benefits must do so in a
				manner which is not ambiguous, deceptive, or misleading, or which suggests that
				the package of fixed indemnity benefits is a substitute for or constitutes
				major medical insurance.
C.
Other fixed indemnity benefit types
Unless otherwise limited by
				this rule, the other fixed indemnity benefits shall be limited to
				hospitalization, outpatient services, ambulance and other transportation
				services, behavioral health services, laboratory and imaging services, in-home
				care, durable medical equipment, home, work or vehicle modifications to
				accommodate disability, therapy services, treatment-related lost wages, health
				care related lodging, pet care and daycare services, or cosmetic services
				relating to a covered accident or illness. Other fixed indemnity benefits may
				be offered as a stand-alone policy or certificate of insurance or as a rider to
				an excepted benefit subject plan. A stand-alone other fixed indemnity plan
				shall include all notices required by this rule at an appropriate reading level
				which is understandable to a prospective insured.
D.
Treatment trigger
Other fixed
				indemnity benefits may be conditioned upon a covered person receiving medical
				care given in a medically appropriate location. A carrier shall not condition
				payment for any such benefit on prior approval of treatment or on medical
				necessity.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.13 - ADDITIONAL REQUIREMENTS FOR SPECIFIED DISEASE PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A specified disease plan is subject to these additional
				  requirements.
A.
General
				requirements
(1) A plan covering a
				single specified disease or combination of specified diseases shall not be sold
				or offered for sale other than as a specified disease plan.
(2) A specified disease plan that conditions
				payment upon a pathological diagnosis shall also provide that if the
				pathological diagnosis is not medically feasible, a clinical diagnosis will be
				accepted.
(3) A specified disease
				plan shall pay a lump-sum upon medical diagnosis of the specified disease, or
				for any form or variation of a specified disease that is covered by the
				plan.
(4) An individual specified
				disease plan shall be guaranteed renewable.
(5) A specified disease plan shall not be
				sold to a person covered by any Title XIX program (Medicaid, Centennial Care or
				any similar name). An individual specified disease plan shall contain a
				statement above the signature line of an individual applicant or covered person
				attesting that the person seeking to be covered for a specified disease is not
				covered by Medicaid. The statement may not be combined with any other statement
				for which the carrier may require the applicant or covered person's signature.
				For group plans, the carrier shall provide a notice in any enrollment materials
				of the above prohibition of sale of a specified disease plan to persons covered
				by Title XIX programs.
(6) Any
				benefit that is conditioned on repeated care for a specified disease shall
				begin with the first day of care even if the diagnosis is made at some later
				date.
(7) A specified disease plan
				shall provide benefits only on a fixed indemnity basis.
(8) A specified disease plan may offer other
				fixed indemnity benefits in compliance with 13.10.34.12.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.14 - ADDITIONAL REQUIREMENTS FOR HOSPICE CARE BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A hospital indemnity plan that provides hospice coverage,
				  separately or in conjunction with other hospital indemnity coverage, is subject
				  to these additional requirements.
A.
Scope
The hospice benefit shall apply to care received in a
				facility or through an in-home program, licensed, certified or registered in
				accordance with state law that provides a formal program of care that is:
(1) for terminally ill patients whose life
				expectancy is less than six months;
(2) provided on an inpatient or outpatient
				basis; and
(3) directed by a
				physician.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.15 - SUPPLEMENTAL PLAN

Current through Register Vol. 35, No. 13, July 16, 2024
A supplemental plan is subject to these additional
				  requirements.
A.
Group coverage
				limitation
A carrier shall only offer or issue a supplemental plan to a
				person who is covered under a primary group major medical, TRICARE or Champus
				plan.
B.
Plan design
A
				supplemental plan must be specifically designed to fill gaps in the primary
				coverage. This requirement is satisfied if the coverage is designed to fill
				gaps in cost-sharing in the primary coverage, such as coinsurance or
				deductibles, or the coverage is designed to provide benefits for items and
				services not covered by the primary coverage and that are not essential health
				benefits as defined under section 1302(b) of the Patient Protection and
				Affordable Care Act in the New Mexico benchmark plan, or the coverage is
				designed to both fill such gaps in cost-sharing under, and cover such benefits
				not covered by, the primary coverage.
C.
No coordination
A
				supplemental plan shall not include a coordination-of-benefits provision but
				may condition payment of benefits on the covered person becoming obligated to
				pay a cost-sharing obligation under the primary coverage.
D.
Indemnity
A supplemental plan
				shall not offer fixed indemnity benefits.
E.
Filing requirement
For each
				supplemental plan filed with the superintendent, the carrier shall also file a
				separate document specifically identifying any offered benefits that are not
				covered by group major medical coverage and are not essential health
				benefits.
F.
Exclusions
A supplemental plan shall include a provision that
				guarantees the plan will not impose an exclusion that does not appear in the
				covered person's group major medical plan.