reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.14 - MINIMUM STANDARDS FOR UNEARNED PREMIUM RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The minimum unearned premium reserve with
				respect to any contract is the pro rata unearned modal premium that applies to
				the premium period beyond the valuation date, with such premium determined on
				the basis of:
(1) the valuation net modal
				premium on the contract reserve basis applying to the contract; or
(2) the gross modal premium for the contract
				if no contract reserve applies.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.15 - PREMIUM RESERVE METHODS GENERALLY

Current through Register Vol. 35, No. 13, July 16, 2024
The insurer may employ suitable approximations and estimates;
				  including, but not limited to groupings, averages and aggregate estimation; in
				  computing premium reserves. Such approximations or estimates should be tested
				  periodically to determine their continuing adequacy and
				  reliability.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.16 - CONTRACT RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
The contract reserve is in addition to claim reserves and
				  premium reserves.
A.
Contract
				reserves required.
Contract reserves are required, unless otherwise
				specified in Subsection B of 13.10.14.16 NMAC, for:
(1) all individual and group contracts with
				which level premiums are used; or
(2) all individual and group contracts with
				respect to which, due to the gross premium pricing structure at issue, the
				value of the future benefits at any time exceeds the value of any appropriate
				future valuation net premiums at that time. The values specified in this
				Paragraph (2) of Subsection A of 13.10.14.16 NMAC shall be determined on the
				basis specified in 13.10.14.17 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.17 - BASIS FOR MINIMUM STANDARDS FOR CONTRACT RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Morbidity or other
				Contingency.
Minimum standards with respect to morbidity are those set
				forth in 13.10.14.22 and 13.10.14.23 NMAC. Valuation net premiums used under
				each contract must have a structure consistent with the gross premium structure
				at issue of the contract as this relates to advancing age of insured, contract
				duration and period for which gross premiums have been calculated.
B.
Unspecified standards.
Contracts for which tabular morbidity standards are not specified in
				13.10.14.22 and 13.10.14.23 NMAC shall be valued using tables established for
				reserve purposes by a qualified actuary and acceptable to the superintendent.
				The morbidity tables shall contain a pattern of incurred claims cost that
				reflects the underlying morbidity and shall not be constructed for the primary
				purpose of minimizing reserves.
C.
Interest.
The maximum interest rate is specified in 13.10.14.24
				NMAC.
D.
Termination
				Rates.
Termination rates used in the computation of reserves shall be on
				the basis of a mortality table as specified in 13.10.14.25 NMAC except as noted
				in Subsection E of 13.10.14.17 NMAC.
E.
Exceeding specified rates.
(1) Under contracts for which premium rates
				are not guaranteed, and where the effects of insurer underwriting are
				specifically used by policy duration in the valuation morbidity standard or for
				return of premium or other deferred cash benefits, total termination rates may
				be used at ages and durations where these exceed specified mortality table
				rates, but not in excess of the lesser of:
(a)
				eighty percent of the total termination rate used in the calculation of the
				gross premiums, or
(b) eight
				percent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.18 - ALTERNATIVE VALUATION METHODS AND ASSUMPTIONS GENERALLY

Current through Register Vol. 35, No. 13, July 16, 2024
Provided the contract reserve on all contracts to which an
				  alternative method or basis is applied is not less in the aggregate than the
				  amount determined according to the applicable standards specified above; an
				  insurer may use any reasonable assumptions as to interest rates, termination
				  and/or mortality rates, and rates of morbidity or other contingency. Also,
				  subject to the preceding condition, the insurer may employ methods other than
				  the methods stated above in determining a sound value of its liabilities under
				  such contracts, including, but not limited to the following: the net level
				  premium method; the one-year full preliminary term method; prospective
				  valuation on the basis of actual gross premiums with reasonable allowance for
				  future expenses; the use of approximations such as those involving age
				  groupings, groupings of several years of issue, average amounts of indemnity,
				  grouping of similar contract forms; the computation of the reserve for one
				  contract benefit as a percentage of, or by other relation to, the aggregate
				  contract reserves exclusive of the benefit or benefits so valued; and the use
				  of a composite annual claim cost for all or any combination of the benefits
				  included in the contracts valued.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.19 - TESTS FOR ADEQUACY AND REASONABLENESS OF CONTRACT RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
Annually, an appropriate review shall be made of the
				  insurer's prospective contract liabilities on contracts valued by tabular
				  reserves, to determine the continuing adequacy and reasonableness of the
				  tabular reserves giving consideration to future gross premiums. The insurer
				  shall make appropriate increments to such tabular reserves if such tests
				  indicate that the basis of such reserves is no longer adequate; subject,
				  however, to the minimum standards of
				  13.10.14.17
				  NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.20 - PREMIUM RATE RESTRICTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In the event a company has a contract or a group of related
				  similar contracts, for which future gross premiums will be restricted by
				  contract, insurance department regulations, or for other reasons, such that the
				  future gross premiums reduced by expenses for administration, commissions, and
				  taxes will be insufficient to cover future claims, the company shall establish
				  contract reserves for such shortfall 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 13.10.14.21 - REINSURANCE

Current through Register Vol. 35, No. 13, July 16, 2024
Increases to, or credits against reserves carried, arising
				  because of reinsurance assumed or reinsurance ceded, must be determined in a
				  manner consistent with these minimum reserve standards and with all applicable
				  provisions of the reinsurance contracts which affect the insurer's
				  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 13.10.14.22 - MINIMUM MORBIDITY STANDARDS FOR VALUATION OF SPECIFIED INDIVIDUAL CONTRACT HEALTH INSURANCE BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Disability Income Benefits Due to Accident or Sickness.
(1)
Contract Reserves.
(a) For contracts issued on or after January
				1, 1997, the 1985 commissioners individual disability tables A (85CIDA); or The
				1985 commissioners individual disability tables B (85CIDB). Each insurer shall
				elect, with respect to all individual contracts issued in any one statement
				year, whether it will use tables A or tables B as the minimum standard. The
				insurer may, however, elect to use the other tables with respect to any
				subsequent statement year.
(b) For
				contracts issued on or after January 1, 1965 and prior to january 1, 1997, the
				1964 commissioners disability table (64 CDT).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.23 - MINIMUM MORBIDITY STANDARDS FOR VALUATION OF SPECIFIED GROUP CONTRACT HEALTH INSURANCE BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Disability Income Benefits Due to Accident or Sickness.
(1)
Contract reserves.
Contracts issued on or after January 1, 1997, the 1987 commissioners group
				disability income table (87CGDT).
(2)
Claim reserves.
(a) For claims incurred on or after January
				1, 1997, the 1987 commissioners group disability income table
				(87CGDT).
(b) For claims incurred
				prior to January 1, 1997, use of the 87CGDT is optional.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.24 - SPECIFIC STANDARDS FOR INTEREST

Current through Register Vol. 35, No. 13, July 16, 2024
A. For contract reserves the maximum interest
				rate is the maximum rate permitted by law in the valuation of whole life
				insurance issued on the same date as the health insurance contract.
B. For claim reserves on policies that
				require contract reserves, the maximum interest rate is the maximum rate
				permitted by law in the valuation of whole life insurance issued on the same
				date as the claim incurral date.
C.
				For claim reserves on policies not requiring contract reserves, the maximum
				interest rate is the maximum rate permitted by law in the valuation of single
				premium immediate annuities issued on the same date as the claim incurral date,
				reduced by one hundred basis points.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.25 - SPECIFIC STANDARDS FOR MORTALITY

Current through Register Vol. 35, No. 13, July 16, 2024
A. Unless Subsection B of 13.10.14.25 NMAC
				applies, the mortality basis used for all policies except long-term care
				individual policies and group certificates and for long-term care individual
				policies and group certificates issued before January 1, 1997 shall be
				according to a table (but without use of selection factors) permitted by law
				for the valuation of whole life insurance issued on the same date as the health
				insurance contract. For long-term care insurance individual policies or group
				certificates issued on or after January 1, 1997, the mortality basis used shall
				be the 1983 group annuity mortality table without projection.
B. Other mortality tables adopted by the NAIC
				and promulgated by the superintendent may be used in the calculation of the
				minimum reserves if appropriate for the type of benefits and if approved by the
				superintendent. The request for such approval must include the proposed
				mortality table and the reason that the standard specified in Subsection A of
				13.10.14.25 NMAC is inappropriate.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.26 - ADJUSTMENT FACTORS

Current through Register Vol. 35, No. 13, July 16, 2024
Duration
Adjustment Factor
Adjusted
Termination
Factor*
Week 1
0.366
0.04831
2
0.366
0.04172
3
0.366
0.04063
4
0.366
0.04355
5
0.365
0.04088
6
0.365
0.04271
7
0.365
0.04380
8
0.365
0.04344
9
0.370
0.04292
10
0.370
0.04107
11
0.370
0.03848
12
0.370
0.03478
13
0.370
0.03034
Month 4
0.391
0.08758
5
0.371
0.07346
6
0.435
0.07531
7
0.500
0.07245
8
0.564
0.06655
9
0.613
0.05520
10
0.663
0.04705
11
0.712
0.04486
12
0.756
0.04309
13
0.800
0.04080
14
0.844
0.03882
15
0.888
0.03730
16
0.932
0.03448
17
0.976
0.03026
18
1.020
0.02856
19
1.049
0.02518
20
1.078
0.02264
21
1.107
0.02104
22
1.136
0.01932
23
1.165
0.01865
24
1.195
0.01792
Year 3
1.369
0.16839
4
1.204
0.10114
5
1.199
0.07434
6 & later
1.000
**
* The adjusted termination rates derived from the application
				  of the adjustment factors to the DTS Valuation Table termination rates shown in
				  exhibits 3a, 3b, 3c, 4, and 5 (
Transactions of the Society of
				  Actuaries
(TSA) XXXVII, pp. 457-463) is displayed. The adjustment
				  factors for age, elimination period, class, sex, and cause displayed in
				  exhibits 3a, 3b, 3c, and 4 should be applied to the adjusted termination rates
				  shown in this table.
** Applicable DTS Valuation Table duration rate from exhibits
				  3c and 4 (TSA XXXVII, pp. 462-463).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to all long-term care insurance policies
				  and life insurance policies that accelerate benefits for long-term care
				  delivered or issued for delivery in this state on or after January 1, 1999 by
				  insurers; fraternal benefit societies; nonprofit health, hospital and medical
				  service corporations; prepaid health plans; health maintenance organizations
				  and all similar organizations. Additionally, this rule is intended to apply to
				  policies having indemnity benefits that are triggered by activities of daily
				  living and sold as disability income insurance, if:
1) the benefits of the disability inicome
				policy are dependent upon or vary in amount based on the receipt of long-term
				care services;
2) the disability
				income policy is advertised, marketed or offered as insurance for long-term
				care services; or
3) benefits under
				the policy may commence after the policyholder has reached Social Security's
				normal retirement age unless benefits are designed to replace lost income or
				pay for specific expenses other than long-term care services.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-9, 59A-23A-6 and 59A-23A-9 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to implement Chapter 59A, Article
				  23A NMSA 1978 to promote the public interest and the availability of long-term
				  care insurance coverage, and to facilitate flexibility and innovation in the
				  development of long-term care insurance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In additon to the definitions in Section 59A-23A-4 NMSA 1978,
				  the following terms have the meanings given here.
A.
"Basis for continuation of
				coverage"
means a policy provision which maintains coverage under the
				existing group policy when such coverage would otherwise terminate and which is
				subject only to the continued timely payment of premium when due.
B.
"Basis for conversion of
				coverage"
means a policy provision that an individual whose coverage
				under the group policy would otherwise terminate or has been terminated for any
				reason, including discontinuance of the group policy in its entirety or with
				respect to an insured class, and who has been continuously insured under the
				group policy (and any group policy which it replaced), for at least six months
				immediately prior to termination, shall be entitled to the issuance of a
				converted policy by the insurer under whose group policy he or she is covered,
				without evidence of insurability.
C.
"Converted policy"
means an
				individual policy of long-term care insurance providing benefits identical to
				or benefits determined by the Superintendent to be substantially equivalent to
				or in excess of those provided under the group policy from which conversion is
				made.
D.
"Exceptional
				increase"
means only those increases filed by an insurer as exceptional
				for which the superintendent determines the need for the premium rate increase
				is justified:
1) due to a change in laws or
				rules applicable to long-term care coverage in this state or
2) due to increased and unexpected
				utilization that affects a majority of insurers of similar products.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.9 - RENEWABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
The terms guaranteed renewable and noncancelable shall not be
				  used in any individual long-term care insurance policy without further
				  explanatory language in accordance with the disclosure requirements of
				  13.10.15.20
				  NMAC.
A. No policy issued to an
				individual shall contain renewal provisions other than guaranteed renewable or
				noncancelable.
B. The term
				guaranteed renewable may be used only when the insured has the right to
				continue the long-term care insurance in force by the timely payment of
				premiums and when the insurer has no unilateral right to make any change in any
				provision of the policy or rider while the insurance is in force, and cannot
				decline to renew, except that rates may be revised by the insurer on a class
				basis.
C. The term noncancelable
				may be used only when the insured has the right to continue the long-term care
				insurance in force by the timely payment of premiums during which period the
				insurer has no right to unilaterally make any change in any provision of the
				insurance or in the premium rate.
D. The term "level premium" may only be used
				when the insurer does not have the right to change the premium.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.10 - LIMITATIONS AND EXCLUSIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. No
				policy may be delivered or issued for delivery in this state as long-term care
				insurance if such policy limits or excludes coverage by type of illness,
				treatment, medical condition or accident, except as follows:
(1) preexisting conditions or
				diseases;
(2) mental or nervous
				disorders; however, this shall not permit exclusion or limitation of benefits
				on the basis of Alzheimer's Disease;
(3) alcoholism and drug addiction;
(4) illness, treatment or medical condition
				arising out of:
(a) war or act of war
				(whether declared or undeclared);
(b) participation in a felony, riot or
				insurrection;
(c) service in the
				armed forces or units auxiliary thereto;
(d) suicide (sane or insane), attempted
				suicide or intentionally self-inflicted injury; or
(e) aviation (this exclusion applies only to
				non-fare-paying passengers).
(5) treatment provided in a government
				facility (unless otherwise required by law), services for which benefits are
				available under Medicare or other governmental program (except Medicaid), any
				state or federal workers compensation, employers liability or occupational
				disease law, or any motor vehicle no-fault law, services provided by a member
				of the covered persons immediate family and services for which no charge is
				normally made in the absence of insurance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.11 - EXTENSION OF BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
Termination of long-term care insurance shall be without
				  prejudice to any benefits payable for institutionalization if such
				  institutionalization began while the long-term care insurance was in force and
				  continues without interruption after termination. Such extension of benefits
				  beyond the period the long-term care insurance was in force may be limited to
				  the duration of the benefit period, if any, or to payment of the maximum
				  benefits and may be subject to any policy waiting period, and all other
				  applicable provisions of the policy.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.12 - CONTINUATION OF COVERAGE OR CONVERSION REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
A. Group long-term care insurance issued in
				this state on or after July 1, 1997 shall provide covered individuals with a
				basis for continuation or conversion of coverage.
B. Continuation of coverage or issuance of a
				converted policy shall be mandatory, except where:
(1) termination of group coverage resulted
				from an individuals failure to make any required payment of premium or
				contribution when due; or
(2) the
				terminating coverage is replaced not later than thirty-one (31) days after
				termination, by group coverage effective on the day following the termination
				of coverage:
(a) providing benefits identical
				to or benefits determined by the Superintendent to be substantially equivalent
				to or in excess of those provided by the terminating coverage; and
(b) the premium for which is calculated in a
				manner consistent with the requirements of Subsection C of 13.10.15.14
				NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.13 - CONTINUATION OF COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Group
				policies which restrict provision of benefits and services to, or contain
				incentives to use, certain providers and/or facilities may provide continuation
				benefits which are substantially equivalent to the benefits of the existing
				group policy. The Superintendent shall make a determination as to the
				substantial equivalency of benefits, and in doing so, shall take into
				consideration the differences between managed care and non-managed care plans,
				including, but not limited to, provider system arrangements, service
				availability, benefit levels and administrative complexity.
B. Notwithstanding any other provision of
				Subsection B of 13.10.15.12 NMAC, any insured individual whose eligibility for
				group long-term care coverage is based upon his or her relationship to another
				person, shall be entitled to continuation of coverage under the group policy
				upon termination of the qualifying relationship by death or dissolution of
				marriage.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.14 - CONVERSION

Current through Register Vol. 35, No. 13, July 16, 2024
A. Where the group
				policy from which conversion is made restricts provision of benefits and
				services to, or contains incentives to use, certain providers and/or
				facilities, the Superintendent, in making a determination as to the substantial
				equivalency of benefits, shall take into consideration the differences between
				managed care and non-managed care plans, including, but not limited to,
				provider system arrangements, service availability, benefit levels and
				administrative complexity.
B.
				Written application for the converted policy shall be made and the first
				premium due, if any, shall be paid as directed by the insurer not later than
				thirty-one (31) days after termination of coverage under the group policy or
				following payment direction of the insurer, if later. The converted policy
				shall be issued effective on the day following the termination of coverage
				under the group policy, and shall be renewable annually.
C. Unless the group policy from which
				conversion is made replaced previous group coverage, the premium for the
				converted policy shall be calculated on the basis of the insured's age at
				inception of coverage under the group policy from which conversion is made.
				Where the group policy from which conversion is made replaced previous group
				coverage, the premium for the converted policy shall be calculated on the basis
				of the insured's age at inception of coverage under the group policy
				replaced.
D. Notwithstanding any
				other provision of Subsection B of 13.10.15.12 NMAC, a converted policy issued
				to an individual who at the time of conversion is covered by another long-term
				care insurance policy which provides benefits on the basis of incurred
				expenses, may contain a provision which results in a reduction of benefits
				payable if the benefits provided under the additional coverage, together with
				the full benefits provided by the converted policy, would result in payment of
				more than 100 percent of incurred expenses. Such provision shall only be
				included in the converted policy if the converted policy also provides for a
				premium decrease or refund which reflects the reduction in benefits
				payable.
E. The converted policy
				may provide that the benefits payable under the converted policy, together with
				the benefits payable under the group policy from which conversion is made,
				shall not exceed those that would have been payable had the individuals
				coverage under the group policy remained in force and effect.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.15 - DISCONTINUANCE AND REPLACEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
If a group long-term care policy is replaced by another group
				  long-term care policy issued to the same policyholder, the succeeding insurer
				  shall offer coverage to all persons covered under the previous group policy on
				  its date of termination. Coverage provided or offered to individuals by the
				  insurer and premiums charged to persons under the new group policy:
A. shall not result in any exclusion for
				preexisting conditions that would have been covered under the group policy
				being replaced; and
B. shall not
				vary or otherwise depend on the individuals health or disability status, claim
				experience or use of long-term care services.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.16 - LIMITATIONS ON PREMIUM RATE INCREASES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The initial premium charged an insured
				covered by a long-term care policy shall not increase during the initial three
				(3) years in which the policy is in force.
B. The premium charged to an insured shall
				not increase due to either:
(1) the
				increasing age of the insured at ages beyond sixty-five (65); or
(2) the duration the insured has been covered
				under the policy.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.17 - UNINTENTIONAL LAPSE

Current through Register Vol. 35, No. 13, July 16, 2024
Each insurer offering long-term care insurance shall, as a
				  protection against unintentional lapse, comply with the following:
A.
Designation of person to receive
				notice.
(1) No individual long-term
				care policy or certificate shall be issued until the insurer has received from
				the applicant either:
(a) a written
				designation of at least one person, in addition to the applicant, who is to
				receive notice of lapse or termination of the policy or certificate for
				nonpayment of premium;
(b) or a
				written waiver dated and signed by the applicant electing not to designate
				additional persons to receive notice.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.18 - REINSTATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the requirement in
				  13.10.15.17
				  NMAC, a long-term care insurance policy or certificate shall include a
				  provision which provides for reinstatement of coverage in the event of lapse if
				  the insurer is provided proof that the policy holder or certificate holder
				  became cognitively impaired or lost functional capacity before the grace period
				  contained in the policy expired. This option shall be available to the insured
				  if requested within five (5) months after termination and shall allow for the
				  collection of past due premium, where appropriate. The standard of proof for
				  cognitive impairment or loss of functional capacity shall not be more stringent
				  than the benefit eligibility criteria on cognitive impairment or the loss of
				  functional capacity, if any, contained in the policy and
				  certificate.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.20 - REQUIRED DISCLOSURE OF RATING PRACTICES TO CONSUMERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. This section shall apply as follows:
(1) Except as provided in Paragraph (2) of
				this subsection, this section applies to any long-term care policy or
				certificate issued in this state on or after January 1, 2004.
(2) For certificates issued on or after the
				effective date of this amended rule under a long-term care insurance policy as
				defined in Paragraph (1) of Subsection C of Section 59A-23A-4 NMSA 1978, which
				policy was in force at the time this amended rule became effective, the
				provisions of this section shall apply on the policy anniversary following July
				1, 2004.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.21 - INITIAL FILING REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				This section applies to any long-term care policy issued in this state on or
				after January 1, 2004.
B. An
				insurer shall provide the information listed in this subsection to the
				superintendent along with the form and rate filing required by law.
(1) A copy of the disclosure documents
				required by 13.10.15.20 NMAC; and
(2) An actuarial certification consisting of
				at least the following:
(a) A statement that
				the initial premium rate schedule is sufficient to cover anticipated costs
				under moderately adverse experience and that the premium rate schedule is
				reasonably expected to be sustainable over the life of the form with no future
				premium rate increases anticipated;
(b) A statement that the policy design and
				coverage provided have been reviewed and taken into consideration;
(c) A statement that the underwriting and
				claims adjudication processes have been reviewed and taken into
				consideration;
(d) A complete
				description of the basis for contract reserves that are anticipated to be held
				under the form, to include:
(i) sufficient
				detail or sample calculations provided so as to have a complete depiction of
				the reserve amounts to be held,
(ii) a statement that the assumptions used
				for reserves contain reasonable margins for adverse experience,
(iii) a statement that the net valuation
				premium for renewal years does not increase (except for attained-age rating
				where permitted), and
(iv) a
				statement that the difference between the gross premium and the net valuation
				premium for renewal years is sufficient to cover expected renewal expenses; or
				if such a statement cannot be made, a complete description of the situation
				where this does not occur. An aggregate distribution of anticipated issues may
				be used as long as the underlying gross premiums maintain a reasonably
				consistent relationship. If the gross premiums for certain age groups appear to
				be inconsistent with this requirement, the superintendent may request a
				demonstration under Subsection C of this section based on a standard age
				distribution.
(e) A
				statement that the premium rate schedule is not less than the premium rate
				schedule for existing similar policy forms also available from the insurer
				except for reasonable differences attributable to benefits; or a comparison of
				the premium schedules for similar policy forms that are currently available
				from the insurer with an explanation of the differences
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.22 - PROHIBITION AGAINST POST-CLAIM UNDERWRITING

Current through Register Vol. 35, No. 13, July 16, 2024
A. All applications for long-term care
				insurance policies or certificates, except those which are guaranteed issue,
				shall contain clear and unambiguous questions designed to ascertain the health
				condition of the applicant.
(1) If an
				application for long-term care insurance contains a question which asks whether
				the applicant has had medication prescribed by a physician, it must also ask
				the applicant to list the medication that has been prescribed.
(2) If the medications listed in such
				application were known by the insurer, or should have been known at the time of
				application, to be directly related to a medical condition for which coverage
				would otherwise be denied, then the policy or certificate shall not be
				rescinded for that condition.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.23 - MINIMUM STANDARDS FOR HOME HEALTH AND COMMUNITY CARE BENEFITS IN LONG-TERM CARE INSURANCE POLICIES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				A long-term care insurance policy or certificate shall not, if it provides
				benefits for home health care or community care services, limit or exclude
				benefits by:
(1) requiring that the
				insured/claimant would need care in a skilled nursing facility if home health
				care services were not provided;
(2) requiring that the insured/claimant first
				or simultaneously receive nursing and/or therapeutic services in a home,
				community or institutional setting before home health care services are
				covered;
(3) limiting eligible
				services to services provided by registered nurses or licensed practical
				nurses;
(4) requiring that a nurse
				or therapist provide services covered by the policy that can be provided by a
				home health aide, or other licensed or certified home care worker acting within
				the scope of his or her licensure or certification;
(5) excluding coverage for personal care
				services provided by a home health aide;
(6) requiring that the provision of home
				health care services be at a level of certification or licensure greater than
				that required by the eligible service;
(7) requiring that the insured/claimant have
				an acute condition before home health care services are covered;
(8) limiting benefits to services provided by
				Medicare-certified agencies or providers; or
(9) excluding coverage for adult day care
				services.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.24 - REQUIREMENT TO OFFER INFLATION PROTECTION

Current through Register Vol. 35, No. 13, July 16, 2024
A. No insurer may offer a long-term care
				insurance policy unless the insurer also offers to the policyholder, in
				addition to any other inflation protection, the option to purchase a policy
				that provides for benefit levels to increase with benefit maximums or
				reasonable durations which are meaningful to account for reasonably anticipated
				increases in the costs of long-term care services covered by the policy.
				Insurers must offer to each policyholder, at the time of purchase, the option
				to purchase a policy with an inflation protection feature no less favorable
				than one of the following:
(1) increases
				benefit levels annually in a manner so that the increases are compounded
				annually at a rate not less than five percent (5%);
(2) guarantees the insured individual the
				right to periodically increase benefit levels without providing evidence of
				insurability or health status so long as the option for the previous period has
				not been declined. The amount of the additional benefit shall be no less than
				the difference between the existing policy benefit and that benefit compounded
				annually at a rate of at least five percent (5%) for the period beginning with
				the purchase of the existing benefit and extending until the year in which the
				offer is made; or
(3) covers a
				specified percentage of actual or reasonable charges and does not include a
				maximum specified indemnity amount or limit.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.25 - REQUIREMENTS FOR APPLICATION FORMS AND REPLACEMENT COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Application
				forms shall include the following questions designed to elicit information as
				to whether, as of the date of the application, the applicant has another
				long-term care insurance policy or certificate in force or whether a long-term
				care policy or certificate is intended to replace any other accident and
				sickness or long-term care policy or certificate presently in force. A
				supplementary application or other form to be signed by the applicant and
				agent, except where the coverage is sold without an agent, containing such
				questions may be used. With regard to a replacement policy issued to a group,
				the following questions may be modified only to the extent necessary to elicit
				information about health or long-term care insurance policies other than the
				group policy being replaced provided, however, that the certificate holder has
				been notified of the replacement.
(1) "Do you
				have another long-term care insurance policy or certificate in force (including
				health care service contract, health maintenance organization
				contract)?"
(2) "Did you have
				another long-term care insurance policy or certificate in force during the last
				twelve (12) months?"
(a) "If so, with which
				company?"
(b) "If that policy
				lapsed, when did it lapse?"
(3) "Are you covered by Medicaid?"
(4) "Do you intend to replace any of your
				medical or health insurance coverage with this policy [certificate]?"
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.28 - REPORTING REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
For purposes of this section, policy means only long-term
				  care insurance and report means on a statewide basis.
A. Every insurer shall maintain records for
				each agent of that agent's amount of replacement sales as a percent of the
				agents total annual sales and the amount of lapses of long-term care insurance
				policies sold by the agent as a percent of the agent's total annual
				sales.
B. Reported replacement and
				lapse rates do not alone constitute a violation of insurance laws or
				necessarily imply wrongdoing. The reports are for the purpose of reviewing more
				closely agent activities regarding the sale of long-term care
				insurance.
C. Each insurer shall
				report annually by June 30th:
(1) the ten
				percent (10%) of its agents with the greatest percentages of lapses and
				replacements as measured by Subsection A of this section.
(2) the number of lapsed policies as a
				percent of its total annual sales and as a percent of its total number of
				policies in force as of the end of the preceding calendar year.
(3) the number of replacement policies sold
				as a percent of its total annual sales and as a percent of its total number of
				policies in force as of the preceding calendar year.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.29 - LICENSING

Current through Register Vol. 35, No. 13, July 16, 2024
No agent is authorized to market, sell, solicit or otherwise
				  contact any person for the purpose of marketing long-term care insurance unless
				  the agent has demonstrated his or her knowledge of long-term care insurance and
				  the appropriateness of such insurance by passing a test required by this state
				  and maintaining appropriate licenses.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.30 - DISCRETIONARY POWERS OF SUPERINTENDENT

Current through Register Vol. 35, No. 13, July 16, 2024
The Superintendent may, upon written request and after an
				  administrative hearing, issue an order to modify or suspend a specific
				  provision of this rule with respect to a specific long-term care insurance
				  policy or certificate upon a written finding that:
A. The modification or suspension would be in
				the best interest of the insureds; and
B. The purposes to be achieved could not be
				effectively or efficiently achieved without the modification or suspension; and
(1) the modification or suspension is
				necessary to the development of an innovative and reasonable approach for
				insuring long-term care; or
(2) the
				policy or certificate is to be issued to residents of a life care or continuing
				care retirement community or some other residential community for the elderly
				and the modification or suspension is reasonably related to the special needs
				or nature of such a community; or
(3) the modification or suspension is
				necessary to permit long-term care insurance to be sold as part of, or in
				conjunction with, another insurance product.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.31 - RESERVE STANDARDS

Current through Register Vol. 35, No. 13, July 16, 2024
A. When
				long-term care benefits are provided through the acceleration of benefits under
				group or individual life policies or riders to such policies, policy reserves
				for such benefits shall be determined in accordance with Section 59A-8-5 NMSA
				1978. Claim reserves must also be established in the case when such policy or
				rider is in claim status.
B.
				Reserves for policies and riders should be based on the multiple decrement
				model utilizing all relevant decrements except for voluntary termination rates.
				Single decrement approximations are acceptable if the calculation produces
				essentially similar reserves, if the reserve is clearly more conservative, or
				if the reserve is immaterial. The calculations may take into account the
				reduction in life insurance benefits due to the payment of long-term care
				benefits. However, in no event shall the reserves for the long-term care
				benefit and the life insurance benefit be less than the reserves for the life
				insurance benefit assuming no long-term care benefit.
C. In the development and calculation of
				reserves, due regard shall be given to the applicable policy provisions,
				marketing methods, administrative procedures and all other considerations which
				have an impact on projected claim costs, including, but not limited to, the
				following:
(1) definition of insured
				events;
(2) covered long-term care
				facilities;
(3) existence of home
				convalescence care coverage;
(4)
				definition of facilities;
(5)
				existence or absence of barriers to eligibility;
(6) premium waiver provision;
(7) renewability;
(8) ability to raise premiums;
(9) marketing method;
(10) underwriting procedures;
(11) claims adjustment procedures;
(12) waiting period;
(13) maximum benefit;
(14) availability of eligible
				facilities;
(15) margins in claim
				costs;
(16) optional nature of
				benefit;
(17) delay in eligibility
				for benefit;
(18) inflation
				protection provisions; and
(19)
				guaranteed insurability option.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.32 - LOSS RATIO

Current through Register Vol. 35, No. 13, July 16, 2024
This section does not apply to policies or certificates
				  providing nonforfeiture benefits in accordance with Subsection C of
				  13.10.15.43
				  NMAC based on acceptance of the offer of non-forfeiture benefits required by
				  Subsection A of
				  13.10.15.43
				  NMAC. This section shall not apply to long-term care insurance policies or
				  certificates covered by
				  13.10.15.20
				  and
				  13.10.15.33
				  NMAC.
A. Effective January 1, 1999,
				benefits under long-term care insurance policies shall be deemed reasonable in
				relation to premiums, provided the expected lifetime loss ratio and future
				expected loss ratio is at least sixty-five percent (65%), calculated in a
				manner which provides for adequate reserving of the long-term care insurance
				risk. In evaluating the expected loss ratio, due consideration shall be given
				to all relevant factors, including:
(1)
				statistical credibility of incurred claims experience and earned
				premiums;
(2) the period for which
				rates are computed to provide coverage;
(3) experienced and projected
				trends;
(4) concentration of
				experience within early policy duration;
(5) expected claim fluctuation;
(6) experience refunds, adjustments or
				dividends;
(7) renewability
				features;
(8) all appropriate
				expense factors;
(9)
				interest;
(10) experimental nature
				of the coverage;
(11) policy
				reserves;
(12) mix of business by
				risk classification; and
(13)
				product features such as long elimination periods, high deductibles and high
				maximum limits.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.33 - PREMIUM RATE SCHEDULE INCREASES

Current through Register Vol. 35, No. 13, July 16, 2024
A. This section shall apply as follows:
(1) Except as provided in paragraph (2), this
				section applies to any long-term care policy or certificate issued in this
				state on or after January 1, 2004.
(2) For certificates issued on or after the
				effective date of this amended rule under a group policy as defined in
				Paragraph (1) of Subsection C of Section 59A-23A-4 NMSA 1978, which policy was
				in force at the time this amended rule became effective, the provisions of this
				section shall apply on the policy anniversary following July 1, 2004.