New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 2 - MOTHERS AND NEWLY BORN CHILDREN HEALTH SECURITY › Section 13.10.2.12 - NONPROFIT HEALTH PLAN CONTRACTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. All subscriber contracts of a nonprofit
				health care plan delivered or issued for delivery in this state and which
				provide maternity coverage shall also provide coverage for a minimum of 48
				hours of inpatient care following a vaginal delivery and a minimum of 96 hours
				of inpatient care following a caesarian section for a mother and her newly born
				child in a health facility unless earlier discharge is made in accordance with
				the medical criteria outlined in the most current version of the "Guidelines
				for Perinatal Care" prepared by the American academy of pediatrics and the
				American college of obstetricians and gynecologists, including, but not limited
				to, the criterion that family members or other support person(s) should be
				available to the mother for the first few days following discharge. In
				addition, a decision for early discharge should be individualized and should be
				a mutual decision between the mother and the attending physician. Inpatient
				care in excess of a minimum of 48 hours following a vaginal delivery and a
				minimum of 96 hours following a caesarian section for a mother and her newly
				born child in a health facility shall be covered if determined to be medically
				necessary by the attending physician.
B. Notwithstanding the provisions of
				sub-section 12.1 of this section [now Subsection A of 13.10.2.12 NMAC], a
				subscriber contract of a nonprofit health care plan delivered or issued for
				delivery in this state that provides coverage for postpartum care for a mother
				and her newly born child in the home shall not be required to provide coverage
				for a minimum of 48 hours of inpatient care following a vaginal delivery and a
				minimum of 96 hours of inpatient care following a caesarian section, unless
				such inpatient care is determined to be medically necessary by the attending
				physician, or early discharge is inconsistent with the most current version of
				the "Guidelines for Perinatal Care" prepared by the American academy of
				pediatrics and the American college of obstetricians and gynecologists, or this
				rule.
C. Postpartum care in the
				home shall be made in accordance with accepted maternal and neonatal physician
				assessments, by a person with appropriate licensure, training and experience to
				provide postpartum care. Services provided by such person shall include, but
				not be limited to, parent education, assistance and training in breast and
				bottle feeding, and the performance of any necessary and appropriate clinical
				tests.
D. Postpartum care in the
				home shall consist of a minimum of three home visits, unless one or two home
				visits are determined to be sufficient by the attending physician or person
				with appropriate licensure, training and experience to provide postpartum care,
				and the mother. The home visits shall be conducted within the time period
				ordered by the attending physician or person with appropriate licensure,
				training and experience to provide postpartum care.
E. Each nonprofit health care plan which
				provides maternity coverage in this state shall mail a written description of
				the coverage required under this rule, in a form approved by the
				superintendent, to the expectant mother covered by the nonprofit health care
				plan and to her attending physician, upon receipt by the nonprofit health care
				plan of notification of the diagnosis of pregnancy of the expectant
				mother.
F. In addition to the
				notification provided in subsection 12.5 [now Subsection E of 13.10.2.12 NMAC],
				each nonprofit health care plan which provides maternity coverage in this state
				shall mail a written statement, in a form approved by the superintendent, to
				the expectant mother covered by the nonprofit health care plan, notifying the
				expectant mother of her right to complain to the superintendent if there is
				concern that the mother or her newly born child has not received the coverage
				required by this rule. In the event of a complaint, the nonprofit health care
				plan will have the burden of proof to demonstrate that the coverage provided
				was in compliance with this rule.