reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.30 - PROHIBITION AGAINST USE OF GENETIC INFORMATION AND REQUESTS FOR GENETIC TESTING

Current through Register Vol. 35, No. 13, July 16, 2024
This Section applies to all policies with policy years
				  beginning on or after May 21, 2009.
A.
Use of genetic testing - exclusion and discrimination.
An issuer
				of a Medicare Supplement policy or certificate;
(1) Shall not deny or condition the issuance
				or effectiveness of the policy or certificate (including the imposition of any
				exclusion of benefits under the policy based on a pre-existing condition) on
				the basis of the genetic information with respect to such individual;
				and
(2) Shall not discriminate in
				the pricing of the policy or certificate (including the adjustment of premium
				rates) of an individual on the basis of the genetic information with respect to
				such individual.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.31 - SEPARABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any provision of this regulation or the application
				  thereof to any person or circumstance is for any reason held to be invalid, the
				  remainder of the regulation and the application of such provision to other
				  persons or circumstances shall not be affected thereby.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to private health insurance cooperatives
				  established under Chapter 59A, Article 23 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-9 and 59A-23-3 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
October 15, 2012, unless a later date is cited at the end of
				  a section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"Private
				health insurance cooperative"
means a nonprofit corporation formed to
				arrange for health benefit plan coverage with insurance carriers for its
				participating member large or small employers.
B.
"Carrier"
means carrier as
				defined in Section 59A-23-11.Q (1) NMSA 1978.
C.
"Large employer"
means a
				large employer as defined in Section 59A-23-11.Q (2) NMSA 1978.
D.
"Small employer"
means a
				small employer as defined in as defined in Section 59A-23-11.Q (3) NMSA
				1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.8 - REGISTRATION REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Any
				private health insurance cooperative operating in New Mexico shall register
				with the agent licensing bureau of the insurance division of the New Mexico
				public regulation commission prior to commencing operations.
B. All business entities should be aware that
				other licensing and registration requirements for corporations and partnerships
				may exist. Corporations may contact the corporations bureau of the New Mexico
				public regulation commission at (505) 827-4387 to determine the applicable
				requirements and to register. Partnerships may contact the secretary of state's
				office (505) 827-3600 to determine the applicable requirements and to
				register.
C. The registration
				process with the agent licensing bureau of the insurance division shall include
				verification that the private health insurance cooperative:
(1) has provided:
(a) name;
(b) New Mexico public regulation commission
				corporations number;
(c) New Mexico
				address as registered;
(d) New
				Mexico city of registration;
(e)
				state and zip code of registration;
(f) sufficient evidence that the entity is in
				good standing with the secretary of state (if the date is not identical to the
				current date, then the agent licensing bureau shall notify the private health
				insurance cooperative that it may not negotiate contracts until its good
				standing is re-established);
(g)
				member-employer names, addresses, cities of registration, states, zip codes,
				and New Mexico tax I.D. numbers; and
(h) the private health insurance
				cooperative's employee names and addresses;
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 26 - REGISTRATION OF PRIVATE HEALTH INSURANCE COOPERATIVES › Section 13.10.26.9 - ANNUAL REQUIRED FILING

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Each private health insurance cooperative shall file an annual report for the
				preceding calendar year with the superintendent on or before March 1 of each
				year, or within such extension of time as the superintendent for good cause may
				grant. The report shall be in the form and contain such matters as the
				superintendent prescribes and shall be verified by at least two officers or two
				partners of the private health insurance cooperative.
B. The annual report shall include the
				complete names and addresses of all insurers with which the private health
				insurance cooperative had an agreement during the preceding fiscal year. If
				requested in writing by the private health insurance cooperative, the names and
				addresses of the insureds may be kept confidential by the
				superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 27 - UNIFORM DEFINITIONS AND STANDARDIZED METHODOLOGIES FOR CALCULATING THE MEDICAL LOSS RATIO › Section 13.10.27.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-2-9,
				  59A-22-50,
				  59A-23C-10,
				  59A-46-51
				  and
				  59A-47-46
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 27 - UNIFORM DEFINITIONS AND STANDARDIZED METHODOLOGIES FOR CALCULATING THE MEDICAL LOSS RATIO › Section 13.10.27.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
As used in this rule:
A.
"health insurer"
means a
				person duly authorized to transact the business of health insurance in the
				state pursuant to the Insurance Code but does not include a person that only
				issues an excepted benefit policy intended to supplement major medical
				coverage, including Medicare supplement, vision, dental, disease-specific,
				accident-only or hospital indemnity-only insurance policies, or that only
				issues policies for long-term care or disability income;
B.
"direct services"
means
				services rendered to an individual by a health insurer or a health care
				practitioner, facility or other provider, including case management, disease
				management, health education and promotion, preventive services, quality
				incentive payments to providers and any portion of an assessment that covers
				services rather than administration and for which an insurer does not receive a
				tax credit pursuant to the Medical Insurance Pool Act or the Health Insurance
				Alliance Act; provided, however, that "direct services" does not include care
				coordination, utilization review or management or any other activity designed
				to manage utilization or services;
C.
"health care plan"
has the
				definition found in Subsection J of Section
				59A-47-3 NMSA
				1978;
D.
"health maintenance
				organization"
has the definition found in Subsection O of Section
				59A-46-2 NMSA
				1978;
E.
"premium
" has
				the definition found in Paragraph (3) of Subsection E of Section
				59A-22-50
				NMSA 1978;
F.
"individually
				underwritten"
means any health care policy, plan or contract issued to
				an individual or family reflecting the characteristics of the family members
				covered; these characteristics include, but are not limited to, place of
				residence, age, gender, and health status;
G.
"carrier"
means health
				maintenance organization, health care plan, and health insurer;
H.
"minimum medical loss ratio"
means the percentage determined in accordance with section 8 of this
				rule;
I. "health product lines"
				means:
(1) all programs utilized by a health
				insurer for the offering of products, including but not limited to:
(a) all private programs, including
				individual, small group and large group;
(b) all public programs, including all
				Medicaid and Medicare and any related or future programs or products;
(c) all other arrangements for the
				procurement of health coverage, including capitated arrangements, self-funded
				arrangements; and
(d) such other
				programs or arrangements that the superintendent may designate by order or
				bulletin; but not
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 27 - UNIFORM DEFINITIONS AND STANDARDIZED METHODOLOGIES FOR CALCULATING THE MEDICAL LOSS RATIO › Section 13.10.27.8 - MINIMUM MEDICAL LOSS RATIOS FOR ALL HEALTH PRODUCT LINES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General
				requirement.
Carriers shall meet the minimum medical loss ratio
				established, and in the manner calculated, under this rule.
B.
Measurement period.
Compliance with the minimum medical loss ratio shall be measured over a rolling
				three-year period. The initial measurement period shall be the years, 2010,
				2011 and 2012. Each year thereafter, the subsequent year shall be added to the
				rolling three-year period and the oldest year shall be removed. For example,
				the second measurement period shall be 2011, 2012 and 2013.
C.
Aggregation.
Medical loss
				ratios shall be calculated on a consolidated level within a state, with
				experience allocated to state based upon the situs of the contract. Experience
				of all affiliates shall be accumulated to the following levels:
(1) individually underwritten health
				policies;
(2) small group
				policies;
(3) large group policies
				and all other policies; and
(4)
				total of all group policies combined.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 27 - UNIFORM DEFINITIONS AND STANDARDIZED METHODOLOGIES FOR CALCULATING THE MEDICAL LOSS RATIO › Section 13.10.27.9 - COMPLIANCE REQUIREMENT FORM

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				An Insurer shall use an OSI approved form to submit minimum loss
				ratios.
B. The form shall be posted
				to the OSI website.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
Office of Superintendent of Insurance (OSI), Life and Health
				  (L&H)
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Applicability.
				This rule applies to all health carriers, including health maintenance
				organizations, individual health plans, group and blanket plans, provider
				service networks, non-profit healthcare plans and third-party payers or their
				agents that provide, offer or administer health benefit plans, including health
				benefit plans and managed health care plans subject to the insurance laws and
				regulations of this state. This rule also applies to all health care providers
				who are licensed to provide health-related services in this state.
B. Timely Payments. This rule addresses the
				timely payment to providers by health carriers for covered services that have
				been provided to the carrier's enrollees or covered persons, the credentialing
				process by which health carriers review and select providers who apply to join
				carriers' networks, and a dispute resolution process to be utilized by
				providers and health carriers to resolve differences pertaining to provider
				credentialing and payment for covered services.
C. Exclusions. This rule does not impose any
				requirement on health carriers as to which providers must be accepted into
				health carriers' networks, specify terms of contracts established between
				health carriers and providers, establish standard reimbursement rates for
				payment by health carriers to in- or out-of-network providers for services, or
				interpret terms of any contract established between a health carrier and its
				enrollees or covered persons.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-16-20;
				  59A-16-21.1, 59A-22-54, 59A-23-14, 59A-46-54, and 59A-47-48 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2017, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to establish a uniform and
				  efficient provider credentialing process and to ensure that providers receive
				  prompt payment from health carriers for clean claims and interest on unpaid
				  claims. This rule also establishes a process for resolving payment-related
				  credentialing disputes between health carriers and providers.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
As used in this rule:
A.
"Business day"
means a
				consecutive 24-hour period, excluding weekends or holidays.
B.
"Claim"
means a request from
				a provider for payment for health care services.
C.
"Clean claim"
means a
				manually or electronically submitted claim from an eligible provider that:
(1) contains substantially all the required
				data elements necessary for accurate adjudication without the need for
				additional information from outside of the health carrier's system;
(2) is not materially deficient or improper,
				including lacking substantiating documentation currently required by the health
				carrier; and
(3) has no particular
				or unusual circumstances requiring special treatment - such as, but not limited
				to, coordination of benefits, pre-existing conditions, subrogation, or
				suspected fraud - that prevents payment from being made by the health carrier
				within 30 days of the date of receipt if submitted electronically or 45 days if
				submitted manually.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.8 - CLAIM SUBMISSION AND CODING CHANGES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General.
(1) Health carriers shall comply with both
				the provisions of this section and with the provisions of 13.10.12 NMAC, which
				provides for standardization of health claim forms.
(2) Claims information, including claim
				status information shall be subject to state and federal patient privacy
				protection laws.
(3) A health
				carrier that has entered into a contract with one or more intermediaries to
				conduct provider credentialing or provide payments to providers shall require
				the intermediary to indicate the name of the intermediary and the name of the
				health carrier for which it is conducting the work when contacting a provider
				on behalf of the health carrier.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.9 - PAYMENT OF CLAIMS, OVERDUE CLAIMS AND CALCULATION OF INTEREST

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Payment of
				claims - timeliness.
(1) Claim
				payment. Health carriers shall promptly pay providers upon receipt of clean
				claims for uncontested covered health care services that the provider has
				supplied.
(2) Timeliness. The
				health carrier shall reimburse the eligible provider within 30 days of the date
				of receipt if the clean claim has been submitted electronically or within 45
				days of the date of receipt if the clean claim has been submitted
				manually.
(3) Prompt payment. For
				purposes of prompt payment, a claim shall be deemed to have been "paid" upon
				one of the following:
(a) a check is mailed
				by the health carrier or its intermediary to the provider; or
(b) an electronic transfer of funds is made
				by the health carrier or its intermediary to the provider.
(4) Reimbursement rate. The health carrier
				shall make payment to the provider based on the standard reimbursement rate as
				specified within the contractual agreement, or as otherwise agreed upon between
				the health carrier and the provider.
(5) Multi-claim payments. A single payment
				made to a provider can serve as payment for multiple claims, but must clearly
				identify each claim and the amount of the claim that has been satisfied by the
				payment. If non-claim payments to a provider are included in a multi-claim
				payment, the nature of those payments must also be clearly
				identified.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.10 - GENERAL PROVIDER CREDENTIALING

Current through Register Vol. 35, No. 13, July 16, 2024
The provisions of this section apply equally to initial
				  credentialing applications and applications for re-credentialing.
A.
Credential verification
				program.
(1) In order to ensure
				accessibility and availability of services, each health carrier shall establish
				a program in accordance with this regulation that verifies that its
				participating providers are credentialed before the health carrier accepts a
				provider into its network and lists a provider in the health carrier's provider
				directory, handbooks, or other marketing or member materials.
(2) The credential verification program
				established by each health carrier shall provide for an identifiable person(s)
				to be responsible for all credential verification activities, which person(s)
				shall be capable of carrying out that responsibility.
(3) A health carrier is not obligated to
				approve all applications for credentialing and may deny any application based
				on existing network adequacy, issues with an application, failure by provider
				to provide a complete credentialing application, or another reason.
(4) No contract between a health carrier and
				a participating provider shall include a clause that has the effect of
				relieving either party of liability for its actions or
				inactions.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.11 - TIMELY CREDENTIALING DECISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Initiation of credentialing
				process.
The credentialing process may be initiated by a provider, who
				either:
(1) provides a completed uniform
				credentialing form directly to the health carrier; or
(2) notifies the health carrier that the
				provider is requesting credentialing by the health carrier, that the provider's
				completed uniform credentialing form is in electronic format and is available
				to the health carrier for access via the credentialing form's website or
				on-line database, and that the health carrier is requested to obtain the
				provider's completed uniform credentialing form.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.12 - REIMBURSEMENT BY HEALTH CARRIER UPON DELAY IN CREDENTIALING PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Terms for
				reimbursement.
A health carrier shall reimburse a provider, subject to
				co-payments, co-insurance, deductibles, or other cost-sharing provisions, for
				any clean claims for covered services, provided that:
(1) the date of service is more than 45
				calendar days after the date the provider requested credentialing from the
				health carrier and either the provider supplied a completed uniform
				credentialing application or made the completed uniform credentialing
				application available for electronic access by the health carrier, including
				submission of any supporting documentation that the health carrier requested in
				writing during the initial 10-day review period;
(2) the health carrier has approved, or has
				failed to approve or deny the applicant's completed uniform credentialing
				application within the timeframe established pursuant to Subsection C of
				13.10.28.11 NMAC;
(3) the provider
				has no past or current license sanctions or limitations, as reported by the New
				Mexico medical board or another pertinent licensing and regulatory agency, or
				by a similar out-of-state licensing and regulatory entity for a provider
				licensed in another state; and
(4)
				the provider has professional liability insurance or is covered under the
				Medical Malpractice Act.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.13 - CREDENTIALING AND PAYMENT DISPUTE RESOLUTION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Internal review process.
(1) Each health carrier shall establish an
				internal process for resolving disputes regarding payment of claims between the
				health carrier and providers arising when a credentialing decision is delayed
				beyond the timeline found in Subsection C of 13.10.28.11 NMAC, the prompt
				payment deadline described in Paragraph (2) of Subsection A of 13.10.28.9 NMAC
				has passed, and payment has not been made.
(2) The internal process shall include
				required notification regarding pending claims and calculation and payment of
				interest on overdue claims, as described in Subsections C and D of 13.10.28.9
				NMAC.
(3) The internal process
				shall provide for resolution of disputes regarding reimbursement rates as
				described in 13.10.28.12 NMAC.
(4)
				At a minimum, the internal review process shall provide for the following:
(a) To initiate a payment dispute, the
				provider shall contact the health carrier in writing to determine the status of
				a claim, to ensure that sufficient documentation supporting the claim has been
				provided, and to determine whether the claim is considered by the health
				carrier to be a clean claim.
(b)
				The health carrier shall respond in writing to a provider's inquiry regarding
				the status of an unpaid claim within 15 days of receiving the
				inquiry.
(c) The health carrier's
				response shall explain its failure or refusal to pay, and the expected date of
				payment if payment is pending.
(5) The internal review process may provide
				specific procedures for resolving payment disputes, including by not limited
				to, the use of medication.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 28 - PROVIDER PAYMENT AND PROVIDER CREDENTIALING REQUIREMENTS › Section 13.10.28.14 - 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 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule requires screening of all uninsured patients
				  receiving health care services in covered facilities to determine eligibility
				  for health insurance programs, and to determine indigency for the purpose of
				  prohibiting medical debt collection for indigent patients.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-2-9
				  NMSA 1978 and New Mexico Senate Bill 71 from the 2021 Regular Session the
				  Patients' Debt Collection Protections Act NMSA Chapter 57.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
To ensure that health care facilities and covered third-party
				  health care providers screen and identify patients who are indigent, eligible
				  for Medicaid or other health insurance, and ensure that medical debt incurred
				  by indigent patients will not be pursued through collection
				  actions.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For definitions of terms contained in this rule, refer the
				  Patients' Debt Collection Protection Act or in Chapter 59A NMSA 1978, unless
				  otherwise noted below.
A.
"Culturally and linguistically appropriate
" means communication
				that meets the following requirements:
(1) the
				provisions of oral and hearing-impaired language services (such as the
				telephone customer assistance hotline) that includes answering questions in any
				applicable non-English language, including ASL, and providing assistance with
				filing claims and reviews in any applicable non-English language;
(2) the provisions of, upon request, a notice
				in any applicable non-English language;
(3) the inclusion of, in the English version
				of all notices, a statement prominently displayed in any applicable non English
				language clearly indicating how to access the language services provided by the
				health care insurer; and
(4) for
				purposes of this definition, with respect to an address in any New Mexico
				county to which a notice is sent, a non-English language is an applicable
				non-English language if ten percent or more of the population residing in the
				county is literate only in the same non-English language, as determined by the
				department of health and human services ("HHS") The counties that meet this ten
				percent standard, as determined by HHS, are found at
http://cciio.cms.gov/resources/factsheets/clas-data.html
and any necessary changes to this list are posted by HHS annually.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.8 - SCREENING FOR INSURANCE AND PROGRAM ELEGIBILITY

Current through Register Vol. 35, No. 13, July 16, 2024
A health care facility shall screen and offer to assist
				  patients in obtaining Medicaid, public and other insurance, accessing public
				  programs that assist with health care costs other financial assistance offered
				  by the facility, before seeking payment for emergency or medically necessary
				  care. All screening shall utilize culturally linguistically appropriate
				  mechanisms for communication including ASL.
A. Health care facilities shall screen
				patients when the patient is registered or within the following time periods:
(a) a patient who is admitted for emergency
				care shall be screened when the patient's condition has been stabilized through
				treatment and prior to discharge;
(b) a patient who is admitted for inpatient
				care shall be screened at the time that the inpatient care is scheduled or
				within 24 hours of admission;
(c) a
				patient who receives outpatient care shall be screened at the time that the
				outpatient care is scheduled and prior to discharge; or
(d) upon request of a patient who is
				scheduled to receive or has received health care services from the health care
				facility.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 29 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.29.9 - INDIGENT PATIENT DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
Collection actions based on charges for health care services
				  and medical debt may not be pursued against an indigent patient.
A. Medical creditors, medical debt buyers,
				and medical debt collectors shall include a notice with each bill sent to a
				patient, informing the patient that a determination of indigency may be
				conducted, if requested, and that if the patient is indigent, no collection
				actions will be pursued. The notice shall be culturally and linguistically
				appropriate, will be on a separate piece of paper, in bold font no smaller than
				12 points, and will provide both a telephone number, email contact and website
				link for the patient to utilize in requesting an indigency
				determination.
B. Medical
				creditors, medical debt buyers, and medical debt collectors shall make a
				determination as to whether a patient is indigent using the following
				methodology:
(a) household income will be
				calculated using the methods used to determine Medicaid eligibility by the New
				Mexico human services department, Title 8 Chapter 200 NMAC, and by the federal
				Medicaid program utilizing the MAGI protocols promulgated by the New Mexico
				human services department;
(b)
				utilizing the most recent federal poverty guidelines, the patient household
				income and household size, the medical creditor shall determine whether the
				patient's income is less than or equal to two hundred percent of the federal
				poverty guidelines; and
(c) in
				determining household income, the medical creditor will consider both permanent
				and temporary income as defined by MAGI.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to every pharmacy benefits manager ("PBM")
				  and health insurance carrier subject to the jurisdiction of the office of
				  superintendent of insurance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  59A-2-9
				  NMSA 1978 and Subsection C of Section
				  59A-61-3
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule establishes operating standards, licensing,
				  reporting and record retention requirements for PBMs to implement and promote
				  the objectives and policies of the Pharmacy Benefits Manager Regulation Act,
				  Chapter 59A, Article 61 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For purposes of this rule and the Pharmacy Benefits Manager
				  Regulation Act:
A.
"Clean
				claim"
has the definition found in Paragraph (1) of Subsection A of
				Section
				59A-16-21.1
				NMSA 1978.
B.
"Client"
means any person with whom a PBM contracts to provide pharmacy benefits
				management services arising out of or relating to pharmacy operations in New
				Mexico.
C.
"Formulary"
is a list of prescription drugs that has been developed by a health insurance
				carrier or its designee that the carrier or health plan in determining
				applicable prescription drug coverage and benefit levels.
D.
"Health insurance carrier"
or
"carrier"
has the definition found in Paragraph (2) of Subsection
				C of Section
				59A-16-21.2
				NMSA 1978.
E.
"Health
				plan"
has the definition found in Paragraph (3) of Subsection A of
				Section
				59A-16-21.1
				NMSA 1978.
F.
"NCPDP"
means the national council for prescription drug program.
G.
"NDC"
means national drug
				code.
H.
"Network
				pharmacy"
means a pharmacy with whom a payor or PBM has contracted to
				provide pharmacy services to persons with an expectation of receiving payment
				directly or indirectly from the carrier.
I.
"Prescription drug claim
				administration"
is administrative services performed in connection with
				the processing, adjudicating and auditing of claims relating to pharmacy
				services.
J.
"Similarly
				situated"
refers to a network pharmacy whose PBM contract is subject to
				the same reimbursement for a claim as a pharmacy whose appeal was
				granted.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.9 - PHARMACY SERVICES ADMINISTRATIVE ORGANIZATION ("PSAO") REGISTRATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Registration required.
A PSAO shall not provide any service in New
				Mexico unless it is registered with the register with the
				superintendent.
B. A PSAO's
				registration application shall be submitted on a form provided by the
				superintendent and shall include:
(1) full
				business name of PSAO;
(2) name,
				business address, phone number and e-mail address for primary
				contact;
(3) name, business
				address, phone number and e-mail address for contact designated to handle
				grievances; and
(4)
				FEIN.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.10 - PHARMACY GRIEVANCES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Health plans subject to 13.10.16 NMAC:
a pharmacy grievance
				relating to a PBM who is performing services for a health plan or carrier
				subject to rule 13.10.16 NMAC shall be governed by that rule.
B. Health plans not subject to 13.10.16 NMAC:
				A pharmacy with a grievance relating to a PBM who is performing services for
				health plan or carrier that is not subject to rule 13.10.16 NMAC may file a
				grievance against the PBM with the superintendent.
(1) A grievance by a pharmacy against a PBM
				shall be in writing on a form provided by the superintendent.
(2) A pharmacy shall submit a grievance
				within six months from the date the pharmacy new or should have known of
				alleged PBM misconduct.
(3) A
				grievance may allege multiple violations against a single PBM.
(4) A pharmacy shall provide supporting
				documentation.
(5) The
				superintendent shall transmit any grievance, including supporting documentation
				to the e-mail contact designated by the PBM to receive grievance.
(6) The superintendent will specify the
				documentation necessary to address the grievance.
(7) A PBM shall have 14 business days from
				receipt of the grievance to respond in writing.
(8) The superintendent may request additional
				documentation. The PBM shall provide any additional documentation in writing
				within 14 business days from the date of the superintendent's
				request.
(9) The superintendent may
				grant a PBM's request for an extension of time.
(10) The superintendent will send a copy of
				all submissions received in connection to a grievance to the opposing
				party.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.12 - MAXIMUM ALLOWABLE COST ("MAC") APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Submission of appeal.
A
				network pharmacy that disputes a MAC reimbursement amount may submit a MAC
				appeal, to the PBM within 21 business days after a network pharmacy receives
				notice of the reimbursement amount. A PSAO may submit a MAC appeal on behalf of
				a network pharmacy.
B.
Appeals mechanism.
A PBM shall provide a mechanism for submitting
				MAC appeals, including the dedicated phone number and electronic mail address
				or website. The phone number shall be manned at a minimum during the hours of
				8:00 a.m. to 5:00 p.m., mountain time. Information about MAC appeals mechanisms
				shall be prominently displayed in any contract or manual provided by a PBM to a
				pharmacy.
C.
Appeal
				instructions on website.
The PBM's website shall prominently display
				instructions for submitting a MAC appeal and instructions for seeking
				assistance in navigating the website. This link shall also be included in the
				PBM's provider manual.
D.
Response to denied appeal(s).
The PBM's response to a denied MAC
				appeal shall include:
(1) the source or
				sources used, including NDC and name of supplier, to determine pricing for the
				maximum allowable cost list specific to that provider.
(2) the date of the last MAC list update for
				the drug which is the subject of the MAC appeal;
(3) documentation evidencing that the drug
				was available for purchase by a pharmacy in New Mexico at the MAC price from a
				national or regional wholesaler at the time of claim submission; and
(4) any other information the PBM deems
				relevant to the MAC appeal.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.13 - SUBMISSION OF A MAC APPEAL

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Submission requirements.
A MAC appeal submission include:
(1) fill date;
(2) BIN number (six digits);
(3) NCPDP (seven digits);
(4) Rx number;
(5) NDC 11 (11 digits);
(6) drug name;
(7) drug strength;
(8) invoice price and net purchase price of
				drug (whole dollar with two decimal places);
(9) total reimbursement (whole dollar with
				two decimal places);
(10) reason
				for review;
(11) any information
				required by contract; and
(12)
				notes (optional).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.14 - SEARCHABLE ONLINE DATABASE OF DRUG PRICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Update timeframe.
A PBM shall
				update its MAC list at least once every seven days.
B.
Searchable online database
				required.
A PBM shall establish a searchable online database that will
				allow a network pharmacy to search MAC list prices for a particular drug for as
				long as the pharmacy has the right to file a MAC appeal or grievance concerning
				a specific fill. The PBM's provider manual shall include instructions for
				accessing the price list on the PBM's website. The provider manual shall be
				transmitted to a newly joined pharmacy within 10 business days from the date of
				execution of a contract with the PBM. A PBM shall provide an updated version of
				its provider manual within 30 days of any revisions to all network
				pharmacies.
C.
Search
				requirements.
The database shall be searchable by NDC or drug name, and
				specific plan identifier.
D.
Drug information.
The information provided for the drug shall
				contain:
(1) NDC;
(2) NDC description;
(3) MAC list price; and
(4) effective date.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.15 - HISTORICAL MAC LIST DATABASE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Searchable list of drugs.
A PBM shall maintain a searchable
				database containing all MAC list pricing for the preceding five years, but no
				earlier than January 14, 2021. The database shall be searchable by these
				criteria:
(1) NDC number;
(2) drug name;
(3) specific health plan; and
(4) removal data.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.16 - ANNUAL REPORT BY PBM

Current through Register Vol. 35, No. 13, July 16, 2024
A PBM applying for license renewal shall submit an annual
				  report to the superintendent's PBM program coordinator with the license renewal
				  application. The annual report shall contain the items outlined in 13.10.30.8
				  NMAC. Failure to comply with these requirements shall result in non-renewal of
				  the license. Information submitted in the annual report is considered PBM data
				  received by the superintendent pursuant to a specific request pursuant to
				  13.10.30.17 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.17 - CONFIDENTIALITY AND CONFLICTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Confidentiality.
Any PBM data received by the superintendent in
				response to a specific request shall be deemed confidential, unless disclosure
				is required for a regulatory purpose, enforcement, rulemaking, to respond to a
				legislative request, or is otherwise required by law or directed by court
				order. Notwithstanding the foregoing, the superintendent may publish aggregated
				data that cannot be traced to a specific PBM, provided any published data is at
				least 12 months old.
B.
Conflicts.
The superintendent shall not share confidential data
				with a consultant or contractor unless that third-party:
(1) discloses all potential conflicts of
				interest;
(2) maintains appropriate
				data safeguards and firewalls; and
(3) executes an agreement prohibiting
				unauthorized disclosure or use of the confidential data.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.18 - COMPLIANCE REPORTING BY PBM

Current through Register Vol. 35, No. 13, July 16, 2024
PBMs shall submit the following information to determine
				  compliance with New Mexico law according to the schedule provided by the
				  superintendent:
A.
Grievance and
				MAC appeal data
. The PBM shall file a log of grievance and MAC appeal
				data using a form specified by the superintendent.
B.
Pharmacy and therapeutics
				("P&T") committee data
. The PBM shall submit the following
				information for any P&T Committee:
(1)
				names of committee members and conflict disclosure statements;
(2) dates and meeting minutes of the P&T
				committee from the prior plan year; and
(3) statement of the P&T committee's
				duties responsibilities, and goals.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.19 - RETALIATION, DISCRIMINATION AND UNFAIR PRACTICES

Current through Register Vol. 35, No. 13, July 16, 2024
A PBM shall not:
A.
Retaliate.
Retaliate against a pharmacy for invoking its rights
				under these rules or the Pharmacy Benefits Manager Regulation Act. Selecting a
				pharmacy that has filed a grievance for audit at a rate disproportionately
				higher than for other network pharmacies may be considered
				retaliation.
B.
Discriminate.
Discriminate against any person or legal entity.
(1) based on any class membership or
				characteristic protected under any state of federal antidiscrimination law
				or
(2) that receives discounts on
				prescription drugs as a result of a state or federal program or law.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.20 - EXAMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Examination.
Pursuant to the examination powers conferred by the
				Insurance Code, the superintendent may examine a PBM for compliance with any
				applicable New Mexico law.
B.
Data calls.
Pursuant to the oversite and supervision powers
				conferred by the Insurance Code, the superintendent may issue a data call to a
				PBM or PSAO.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.21 - MAINTENANCE OF INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
Every PBM shall maintain at its principal administrative
				  office for the duration of the written agreement referred to in Section
				  59A-12A-4
				  NMSA 1978 and five years thereafter adequate books and records of all contracts
				  and transactions. The superintendent shall have access to such books and
				  records for the purpose of examination, audit and inspection. A PBM may request
				  that certain records be deemed confidential through the process established by
				  OSI. The release of any confidential information shall only be made pursuant to
				  law.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.23 - HEARING RIGHTS

Current through Register Vol. 35, No. 13, July 16, 2024
Any person aggrieved by any action, threatened action, or
				  failure to act by the superintendent shall have the same right to a hearing
				  before the superintendent with respect thereto as provided for in general under
				  Chapter 59A, Article 4 NMSA 1978 and the implementing rules.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 30 - PHARMACY BENEFITS MANAGERS › Section 13.10.30.24 - RULE NONCOMPLIANCE

Current through Register Vol. 35, No. 13, July 16, 2024
Failure to comply with any provision of these rules is a
				  violation of the Insurance Code and punishable pursuant to Subsection B of
				  Section
				  59A-1-18 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 31 - PRIOR AUTHORIZATION › Section 13.10.31.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules apply to every:
A. health insurer as defined in Subsection H
				of Section 59A-22B-2 NMSA 1978;
B.
				multiple employer welfare arrangement; and
C. Medicaid managed care organization, that
				requires prior authorization as a condition to payment for a medical service,
				pharmaceutical, or medical supply benefit. The subject entities are referred to
				collectively herein as "carriers" and individually as a "carrier." The
				requirements of these rules supersede any conflicting provision of any rule
				previously adopted by the superintendent, and are superseded by any conflicting
				provision of federal or state law applicable to a Medicaid managed care
				organization.