New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 2 - MOTHERS AND NEWLY BORN CHILDREN HEALTH SECURITY › Section 13.10.2.13 - NEW MEXICO COMPREHENSIVE HEALTH INSURANCE POOL POLICIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. All pool policies delivered or issued for
				delivery in this state by the New Mexico comprehensive health insurance pool
				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 subsection 13.1 of this section [now Subsection A of 13.10.2.13
				NMAC], a pool policy delivered or issued for delivery in this state that
				provides coverage for postpartum care to a mother and her newly born child in
				the home shall not be required to provide for coverage for a minimum of 48
				hours of inpatient care following a vaginal delivery and a minimum of 96 hours
				of inpatient care following a caesarian section, unless such inpatient care is
				determined to be medically necessary by the attending physician, or early
				discharge is inconsistent with the most current version of the "Guidelines for
				Perinatal Care" prepared by the American academy of pediatrics and the American
				college of obstetricians and gynecologists, or this rule.
C. Postpartum care in the home shall be made
				in accordance with accepted maternal and neonatal physician assessments, by a
				person with appropriate licensure, training and experience to provide
				postpartum care. Services provided by such person shall include, but not be
				limited to, parent education, assistance and training in breast and bottle
				feeding, and the performance of any necessary and appropriate clinical
				tests.
D. Postpartum care in the
				home shall consist of a minimum of three home visits, unless one or two home
				visits are determined to be sufficient by the attending physician or person
				with appropriate licensure, training and experience to provide postpartum care,
				and the mother. The home visits shall be conducted within the time period
				ordered by the attending physician or person with appropriate licensure,
				training and experience to provide postpartum care.
E. Each insurer providing coverage through
				the New Mexico comprehensive health insurance pool under a policy 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 insurer and to her
				attending physician, upon receipt by the insurer of notification of the
				diagnosis of pregnancy of the expectant mother.
F. In addition to the notification provided
				in subsection 13.5 [now Subsection E of 13.10.2.13 NMAC], each insurer
				providing coverage through the New Mexico comprehensive health insurance pool
				under a policy 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 insurer, 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 insurer will have the burden of proof to demonstrate that the
				coverage provided was in compliance with this rule.