reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This rule applies to all health care insurers that
				provide, offer, or administer managed health care plans subject to the
				Insurance Code of the state of New Mexico:
B.
Exemptions.
This rule does
				not apply to policies or certificates that provide coverage for:
(1) only short-term travel, accident-only,
				student health, specified disease, or other limited benefits; or
(2) credit, disability income, hospital
				indemnity, long-term care insurance, vision care or any other limited
				supplemental benefit.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-1-18, 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5,
				  59A-59A-15 -16, 59A-16-4, 59A-16-5, 59A-16-11, 59A-16-12, 59A-16-12.1,
				  59A-16-13, 59A-16-15, 59A-16-16, 59A-16-17, 59A-18-16, 59A-19-4, 59A-19-5,
				  59A-19-6, 59A-23E-15, 59A-44-34, 59A-44-41, 59A-46-7, 59A-46-8, 59A-46-23,
				  59A-46-25, 59A-46-27, 59A-46-30, 59A-46-32, 59A-46-34, 59A-47-33, 59A-47-34,
				  59A-57-2, 59A-57-4, 59A-57-6, and 59A-57-11, NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to clarify contracting between
				  both the health care insurer and enrollees and health care providers under
				  managed health care plans.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. In addition to
				the following, this rule is subject to the definitions found in Managed Health
				Care - Benefits, 13.10.13 NMAC.
B.
"Medical record"
means all information maintained by a health
				care provider relating to the past, present or future physical or mental health
				of a patient, and for other provision of health care to a patient. This
				information includes, but is not limited to, the health care provider's notes,
				reports and summaries, and x-rays and laboratory and other diagnostic test
				results. A patient's complete medical record includes information generated and
				maintained by the health care provider, as well as information provided to the
				health care provider by the patient, by any another health care provider who
				has consulted with or treated the patient, and other information acquired by
				the health care provider about the patient in connection with the provision of
				health care to the patient. A medical record does not include medical billing,
				insurance forms or correspondence and communication related thereto.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.9 - TERMINATION OF COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. A MHCP
				shall not cancel the coverage of an enrollee except for "good cause," which,
				for the purposes of this section means:
(1)
				failure of the enrollee or subscriber to pay the premiums and other applicable
				charges for coverage;
(2) material
				failure to abide by the rules, and/or policies and procedures of the
				MHCP;
(3) fraud or material
				misrepresentation affecting coverage;
(4) a reason for cancellation or failure to
				renew which the superintendent determines is not objectionable.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.10 - MEDICAL RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Transfer of medical records.
Each health care insurer shall develop and
				implement a policy for the transfer of medical records of a covered person
				whenever the following occur:
(1) change of
				physician or other health care professional;
(2) disenrollment of enrollee from the
				managed health care plan; or
(3)
				other circumstances where requests by covered persons or former covered persons
				is reasonable.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.11 - NONDISCRIMINATION BY HEALTH CARE INSURERS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Guaranteed renewability:
(1) In addition to the guaranteed
				renewability provisions pertaining to individuals, pursuant to NMSA 1978,
				Section 59A-23E-19, and under group health plans, pursuant to NMSA 1978,
				Section 59A-23E-14, health care insurers through managed health care plans are
				prohibited from establishing rules for continued eligibility of any individual
				to continue to participate in a health plan based on any of the following:
(a) gender, race, color, national origin,
				ancestry, religion or marital status;
(b) sexual orientation;
(c) age or the age of any contracting party,
				or person reasonably expected to benefit from any such contract as a covered
				person;
(d) health status related
				factors, and
(e) filing of a
				grievance or utilization management appeal as permitted by this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.12 - DECEPTIVE HEALTH CARE INSURER OR MANAGED HEALTH CARE PLAN NAME

Current through Register Vol. 35, No. 13, July 16, 2024
A. A health care
				insurer or managed health care plan shall not use a deceptive name.
B. A name will be considered deceptive if it
				unreasonably suggests:
(1) the quality of
				care provided by the health care insurer or managed health care plan;
(2) that full benefits are provided for
				health care or a specialized area of health care;
(3) that the cost of benefits to enrollees of
				the MHCP is lower than the cost of similar benefits purchased elsewhere;
				and
(4) in any such case where the
				express or implied representation contained in the name is demonstrably untrue
				or is not supported by substantial evidence at all times while such name is
				used by the health care insurer or MHCP.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.13 - ADVERTISING AND SOLICITATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Deceptive advertising prohibited.
No health care insurer may
				cause or knowingly permit the use of advertising or solicitation that is untrue
				or misleading, or may cause or knowingly permit any form of summary of benefits
				or evidence of coverage which is deceptive.
B.
Approval required.
All
				materials, including, but not limited to, solicitation documents and texts of
				media advertising to be employed by the health care insurer for the purpose of
				personally soliciting individual or group enrollees shall be submitted, in a
				form as prescribed by Section 59A-46-5 NMSA 1978 and 13.10.4.18 NMAC, to the
				superintendent prior to the health care insurer's use of such materials. If
				such material has not been disapproved by the superintendent within 30 days of
				its receipt, it shall be deemed approved until such time the superintendent
				issues a specific disapproval in writing.
C.
Information to be included in
				solicitation.
Any solicitation document employed by the health care
				insurer for the purpose of soliciting individual or group enrollees shall
				provide a link, contact or other information which would allow the consumer to
				find the following:
(1) all information
				necessary to enable a consumer of reasonable understanding, not possessing
				special knowledge regarding health care coverage, to make an informed choice as
				to whether or not to enroll with the health care insurer or in the
				MHCP;
(2) a specific description of
				the health care services available;
(3) a current list of providers, including
				health care professionals and facilities; and
(4) the obligations, including financial
				obligations, required of enrollees who join the MHCP.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.14 - CONTINUATION AND TRANSITION OF TREATMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Each health care insurer shall offer continuation and
				  transition of treatment to covered persons in compliance with the Insurance
				  Code and applicable rules.
A. If a
				covered person's health care provider leaves the MHCP's network of providers,
				the MHCP shall permit the covered person to continue an ongoing course of
				treatment with the provider for a transitional period.
B. For all covered persons except those
				addressed Subsection C of 13.10.23.14 NMAC, the transitional period shall
				continue for a time that is sufficient to permit coordinated transition
				planning consistent with the patient's condition and needs relating to
				continuity of case, and, in any event, shall not be not less than thirty
				days.
C. If a covered person has
				entered the third trimester of pregnancy at the time of the provider's
				disaffiliation, and the MHCP offers maternity coverage, the transitional period
				shall include the provision of post-partum care directly related to the
				delivery.
D. The MHCP will not be
				required to permit the covered person to continue treatment with the current
				provider if the provider's disaffiliation with the MHCP was for reasons related
				to medical competence or professional behavior.
E. For transitional periods exceeding thirty
				days, the MHCP shall authorize continued care as provided in this section only
				if the health care provider agrees:
(1) to
				accept reimbursement from the MHCP at the rates applicable prior to the start
				of the transitional period as payment in full;
(2) to adhere to the MHCP's quality assurance
				requirements and to provide to the MHCP necessary medical information related
				to such care; and
(3) to otherwise
				adhere to the MHCP's policies and procedures, including but not limited to
				procedures regarding referrals, pre-authorization and treatment planning
				approved by the MHCP.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.15 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any applicable suspension, revocation or
				  refusal to continue any certificate of authority or license under the Insurance
				  Code, a penalty for any material violation of this rule may be imposed against
				  a health care insurer by the superintendent in accordance with Sections
				  59A-1-18 and 59A-46-25 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.16 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any section of this rule, or the applicability of any
				  section to any person or circumstance, is for any reason held invalid by a
				  court of competent jurisdiction, the remainder of the rule, or the
				  applicability of such provisions to other persons or circumstances, shall not
				  be affected.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to all insurers issuing or delivering in
				  the state of New Mexico medicare supplement policies, certificates or contracts
				  with policy years beginning on or after May 21, 2009.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-9 and 59A-24A-1 et seq. NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
May 26, 2009, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to provide for nondiscrimination
				  based on genetic information in the issuance and pricing of medicare supplement
				  policies or certificates of coverage, and to generally prohibit insurers'
				  requests for genetic testing except for limited use in determining payment for
				  treatment and for genetic testing when used as part of certain scientific
				  research using human subjects.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.8 - NONDISCLOSURE REQUIREMENTS AND EXCEPTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. 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 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.9 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any applicable suspension, revocation or
				  refusal to continue any certificate of authority or license under the insurance
				  code, a penalty for any material violation of this rule may be imposed against
				  a health care insurer by the superintendent in accordance with Sections
				  59A-1-18 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 24 - GENETIC INFORMATION NONDISCRIMINATION - MEDICARE SUPPLEMENT PLANS › Section 13.10.24.10 - 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 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Except as
				otherwise specifically provided in Sections 10, 19, 20, 23 and 28 of 13.10.25
				NMAC this regulation shall apply to:
(1) All
				Medicare Supplement policies delivered or issued for delivery in this state
				before or after the effective date of this regulation; and
(2) All certificates issued under group
				Medicare Supplement policies, which certificates have been delivered or issued
				for delivery in this state.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section
				  59A-2-9,
				  Subsection D of Section
				  59A-18-12,
				  Subsection B of Section
				  59A-18-13,
				  Paragraph (4) of Subsection A of Section
				  59A-23-3
				  and Section
				  59A-24A-1 et seq.
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.5 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this regulation is to provide for the
				  reasonable standardization of coverage and simplification of terms and benefits
				  of Medicare Supplement policies; to facilitate public understanding and
				  comparison of such policies; to eliminate provisions contained in such policies
				  which may be misleading or confusing in connection with the purchase of such
				  policies or with the settlement of claims; and to provide for full disclosures
				  in the sale of accident and sickness insurance coverages to persons eligible
				  for Medicare.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For purposes of this regulation:
A.
"1990 Standardized Medicare
				Supplement benefit plan," "1990 standardized benefit plan"
or
"1990 Plan"
means a group or individual policy of Medicare
				Supplement insurance issued on or after July 1, 1992 with an effective date
				prior to June 1, 2010 and includes Medicare Supplement insurance policies and
				certificates renewed on or after that date which are not replaced by the issuer
				at the request of the insured.
B.
"2010 Standardized Medicare Supplement benefit plan," "2010 standardized
				benefit plan"
or
"2010 plan"
means a group or individual
				policy of Medicare Supplement insurance issued on or after June 1,
				2010.
C.
"Activities of daily
				living"
include, but are not limited to bathing, dressing, personal
				hygiene, transferring, eating, ambulating, administration of drugs that are
				normally self-administered, and changing bandages or other dressings.
D.
"Applicant"
means:
(1) In the case of an individual Medicare
				Supplement policy, the person who seeks to contract for insurance benefits,
				and
(2) In the case of a group
				Medicare Supplement policy, the proposed certificate
				holder.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.8 - POLICY DEFINITIONS AND TERMS

Current through Register Vol. 35, No. 13, July 16, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this state as a Medicare Supplement policy or
				  certificate unless the policy or certificate contains definitions or terms that
				  conform to the requirements of this section.
A.
"Accident," "accidental
				injury,"
or
"accidental means"
shall be defined to employ
				"result" language and shall not include words that establish an accidental
				means test or use words such as "external, violent, visible wounds" or similar
				words of description or characterization.
(1)
				The definition shall not be more restrictive than the following: "Injury or
				injuries for which benefits are provided means accidental bodily injury
				sustained by the insured person which is the direct result of an accident,
				independent of disease or bodily infirmity or any other cause, and occurs while
				insurance coverage is in force."
(2) The definition may provide that injuries
				shall not include injuries for which benefits are provided or available under
				any workers' compensation, employer's liability or similar law, or motor
				vehicle no-fault plan, unless prohibited by law.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.9 - PROHIBITED POLICY PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Except for permitted preexisting condition clauses as described in Paragraph
				(1) of Subsection A of
				13.10.25.10
				NMAC, Paragraph (1) of Subsection A of
				13.10.25.11
				NMAC, and Paragraph (1) of Subsection A of
				13.10.25.13
				NMAC, no policy or certificate may be advertised, solicited or issued for
				delivery in this state as a Medicare Supplement policy if the policy or
				certificate contains limitations or exclusions on coverage that are more
				restrictive than those of Medicare.
B. No Medicare Supplement policy or
				certificate may use waivers to exclude, limit or reduce coverage or benefits
				for specifically named or described preexisting diseases or physical
				conditions.
C. No Medicare
				Supplement policy or certificate in force in the state shall contain benefits
				that duplicate benefits provided by Medicare.
D.
Outpatient prescription
				drugs:
(1) Subject to Paragraphs (4)
				of Subsection A and Subsection B of
				13.10.25.10
				NMAC and Paragraphs (4) of Subsection A and Subsection B of
				13.10.25.11
				NMAC, a Medicare Supplement policy with benefits for outpatient prescription
				drugs in existence prior to January 1, 2006 shall be renewed for current
				policyholders who do not enroll in Medicare Part D at the option of the
				policyholder.
(2) A Medicare
				Supplement policy with benefits for outpatient prescription drugs shall not be
				issued after December 31, 2005.
(3)
				After December 31, 2005, a Medicare Supplement policy with benefits for
				outpatient prescription drugs may not be renewed after the policyholder enrolls
				in Medicare Part D at the option of the policyholder unless:
(a) The policy is modified to eliminate
				outpatient prescription coverage for expenses of outpatient prescription drugs
				incurred after the effective date of the individual's coverage under a Medicare
				Part D plan and;
(b) Premiums are
				adjusted to reflect the elimination of outpatient prescription drug coverage at
				the time of Medicare Part D enrollment, accounting for any claims paid, if
				applicable.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.10 - MINIMUM BENEFIT STANDARDS FOR PRE-STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992

Current through Register Vol. 35, No. 13, July 16, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this state as a Medicare Supplement policy or
				  certificate unless it meets or exceeds the following minimum standards. These
				  are minimum standards and do not preclude the inclusion of other provisions or
				  benefits which are not inconsistent with these standards.
A.
General standards.
The
				following standards apply to Medicare Supplement policies and certificates and
				are in addition to all other requirements of this regulation.
(1)
Preexisting conditions.
A
				Medicare Supplement policy or certificate shall not exclude or limit benefits
				for losses incurred more than six months from the effective date of coverage
				because it involved a preexisting condition. The policy or certificate shall
				not define a preexisting condition more restrictively than a condition for
				which medical advice was given or treatment was recommended by or received from
				a physician within six months before the effective date of coverage.
(2)
Losses from sickness.
A
				Medicare Supplement policy or certificate shall not indemnify against losses
				resulting from sickness on a different basis than losses resulting from
				accidents.
(3)
Cost sharing.
A Medicare Supplement policy or certificate shall provide that benefits
				designed to cover cost sharing amounts under Medicare will be changed
				automatically to coincide with any changes in the applicable Medicare
				deductible, co-payment, or coinsurance amounts. Premiums may be modified to
				correspond with such changes.
(4)
Cancellation and termination.
A "non-cancellable," "guaranteed
				renewable" or "non-cancellable and guaranteed renewable" Medicare Supplement
				policy shall not:
(a) provide for termination
				of coverage of a spouse solely because of the occurrence of an event specified
				for termination of coverage of the insured, other than the nonpayment of
				premium; or
(b) be cancelled or
				non-renewed by the issuer solely on the grounds of deterioration of
				health.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.11 - BENEFIT STANDARDS FOR 1990 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED OR DELIVERED ON OR AFTER JULY 1, 1992 AND PRIOR TO JUNE 1, 2010

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General Standards.
The following standards apply to 1990 Benefit
				Standardized Plan policies and certificates and are in addition to all other
				requirements of this regulation.
(1)
Preexisting conditions.
Refer to Paragraph (1) of Subsection A of
				13.10.25.10
				NMAC.
(2)
Loss from
				sickness.
Refer to Paragraph (2) of Subsection A of
				13.10.25.10
				NMAC.
(3)
Cost
				sharing.
Refer to Paragraph (3) of Subsection A of
				13.10.25.10
				NMAC. An increase in premium shall not be effective without 60 days-notice to
				the policyholder.
(4)
Termination of spousal coverage.
No Medicare Supplement policy or
				certificate shall provide for termination of coverage of a spouse solely
				because of the occurrence of an event specified for termination of coverage of
				the insured, other than the nonpayment of premium.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.13 - BENEFIT STANDARDS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010

Current through Register Vol. 35, No. 13, July 16, 2024
The following standards are applicable to all Medicare
				  Supplement policies or certificates delivered or issued for delivery in this
				  state with an effective date for coverage on or after June 1, 2010. No policy
				  or certificate may be advertised, solicited, delivered, or issued for delivery
				  in this state as a Medicare Supplement policy or certificate unless it complies
				  with these benefit standards. No issuer may offer any 1990 Standardized
				  Medicare Supplement benefit plan for sale on or after June 1, 2010. Benefit
				  standards applicable to Medicare Supplement policies and certificates issued
				  with an effective date of coverage before June 1, 2010 remain subject to the
				  requirements of
				  13.10.25.11
				  NMAC.
A.
General
				standards.
The following standards apply to 2010 Standardized Benefit
				Plan policies and certificates and are in addition to all other requirements of
				this regulation.
(1)
Preexisting
				conditions.
Refer to Paragraph (1) of Subsection A of
				13.10.25.11
				NMAC.
(2)
Losses from
				sickness.
Refer to Paragraph (2) of Subsection A of
				13.10.25.11
				NMAC.
(3)
Cost
				sharing.
Refer to Paragraph (3) of Subsection A of
				13.10.25.11
				NMAC.
(4)
Termination of
				spousal coverage.
Refer to Paragraph (4) of Subsection A of
				13.10.25.11
				NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.14 - STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010

Current through Register Vol. 35, No. 13, July 16, 2024
The following standards are applicable to all Medicare
				  Supplement policies or certificates delivered or issued for delivery in this
				  state on or after June 1, 2010. No policy or certificate may be advertised,
				  solicited, delivered or issued for delivery in this state as a Medicare
				  Supplement policy or certificate unless it complies with these benefit plan
				  standards. Benefit plan standards applicable to Medicare Supplement policies
				  and certificates issued before June 1, 2010 remain subject to the requirements
				  of
				  13.10.25.12
				  NMAC.
A.
Benefit
				requirements:
(1) An issuer shall make
				available to each prospective policyholder and certificate holder a policy form
				or certificate form containing only the basic (core) benefits, as defined in
				Subsection D of
				13.10.25.13
				NMAC of this regulation.
(2) If an
				issuer makes available any of the additional benefits described in Subsection E
				of
				13.10.25.13
				NMAC, or offers standardized benefit Plans K or L (as described in Paragraphs
				(8) and (9) of Subsection E of this section), then the issuer shall make
				available to each prospective policyholder and certificate holder, in addition
				to a policy form or certificate form with only the basic (core) benefits as
				described in Paragraph (1) of this subsection, a policy form or certificate
				form containing either standardized benefit Plan C (as described in Paragraph
				(3) of Subsection of E of this section) or standardized benefit Plan F (as
				described in Paragraph (5) of Subsection E of this
				section).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.15 - STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2020 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY TO INDIVIDUALS NEWLY ELIGIBLE FOR MEDICARE ON OR AFTER JANUARY 1, 2020

Current through Register Vol. 35, No. 13, July 16, 2024
The
Medicare Access and CHIP Reauthorization Act of
				  2015
(MACRA) requires the following standards are applicable to all
				  Medicare Supplement policies or certificates delivered or issued for delivery
				  in this state to individuals newly eligible for Medicare on or after January 1,
				  2020. No policy or certificate that provides coverage of the Medicare Part B
				  deductible may be advertised, solicited, delivered or issued for delivery in
				  this state as a Medicare Supplement policy or certificate to individuals newly
				  eligible for Medicare on or after January 1, 2020. All policies must comply
				  with the following benefit standards. Benefit plan standards applicable to
				  Medicare Supplement policies and certificates issued to individuals eligible
				  for Medicare before January 1, 2020, remain subject to the requirements of
				  13.10.25.11
				  NMAC.
A.
Benefit
				Requirements.
The standards and requirements of
				13.10.25.14
				NMAC shall apply to all Medicare Supplement policies or certificates delivered
				or issued for delivery to individuals newly eligible for Medicare on or after
				January 1, 2020, with the following exceptions:
(1) Standardized Medicare Supplement Benefit
				Plan C is redesignated as Plan D and shall provide the benefits contained in
				Paragraph (3) of Subsection E of
				13.10.25.14
				NMAC but shall not provide coverage for one-hundred percent or any portion of
				the Medicare Part B deductible.
(2)
				Standardized Medicare Supplement Benefit Plan F is redesignated as Plan G and
				shall provide the benefits contained in Paragraph (5) of Subsection E of
				13.10.25.14
				NMAC but shall not provide coverage for one-hundred percent or any portion of
				the Medicare Part B deductible.
(3)
				Standardized Medicare Supplement Benefit Plan F with High Deductible is
				redesignated as Plan G with High Deductible and shall provide the benefits
				contained in Paragraph (6) of Subsection E of
				13.10.25.14
				NMAC but shall not provide coverage for one-hundred percent or any portion of
				the Medicare Part B deductible; provided further that, the Medicare Part B
				deductible paid by the beneficiary shall be considered an out-of-pocket expense
				in meeting the annual high deductible.
(4) Standardized Medicare Supplement Benefit
				Plans C, F, and F with High Deductible may not be offered to individuals newly
				eligible for Medicare on or after January 1, 2020.
(5) The reference to Plans C or F contained
				in Paragraph (2) of Subsection A of
				13.10.25.14
				NMAC is deemed a reference to Plans D or G for purposes of this
				section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.16 - MEDICARE SELECT POLICIES AND CERTIFICATES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
(1) This section shall apply to Medicare
				Select policies and certificates, as defined in this section.
(2) No policy or certificate may be
				advertised as a Medicare Select policy or certificate unless it meets the
				requirements of this section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.17 - OPEN ENROLLMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Plan availability.
An issuer shall not deny or condition the
				issuance or effectiveness of any Medicare Supplement policy or certificate
				available for sale in this state, nor discriminate in the pricing of a policy
				or certificate because of the health status, claims experience, receipt of
				health care, or medical condition of an applicant in the case of an application
				for a policy or certificate that is submitted prior to or during the six month
				period beginning with the first day of the first month in which an individual
				is both 65 years of age or older and is enrolled for benefits under Medicare
				Part B. Each Medicare Supplement policy and certificate currently available
				from an insurer shall be made available to all applicants who qualify under
				this subsection without regard to age.
B.
Period of creditable
				coverage.
(1) If an applicant
				qualifies under Subsection A of this section and submits an application during
				the time period referenced in Subsection A and, as of the date of application,
				has had a continuous period of creditable coverage of at least six months, the
				issuer shall not exclude benefits based on a preexisting condition.
(2) If the applicant qualifies under
				Subsection A of this section and submits an application during the time period
				referenced in Subsection A and, as of the date of application, has had a
				continuous period of creditable coverage that is less than six months, the
				issuer shall reduce the period of any preexisting condition exclusion by the
				aggregate of the period of creditable coverage applicable to the applicant as
				of the enrollment date. The secretary shall specify the manner of the reduction
				under this subsection.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.18 - GUARANTEED ISSUE FOR ELIGIBLE PERSONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Guaranteed issue.
(1)
Eligibility.
Eligible
				persons, as defined in the
Balanced Budget Act of 1997
, are
				those individuals described in Subsection B of this section who seek to enroll
				under the policy during the period specified in Subsection C of this section,
				and who submit evidence of the date of termination, disenrollment, or Medicare
				Part D enrollment with the application for a Medicare Supplement
				policy.
(2)
Discrimination,
				denial and exclusion.
With respect to eligible persons, an issuer shall
				not deny or condition the issuance or effectiveness of a Medicare Supplement
				policy described in Subsection E of this section that is offered and is
				available for issuance to new enrollees by the issuer, shall not discriminate
				in the pricing of such a Medicare Supplement policy because of health status,
				claims experience, receipt of health care, or medical condition, and shall not
				impose an exclusion of benefits based on a preexisting condition under such a
				Medicare Supplement policy.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.19 - STANDARDS FOR CLAIMS PAYMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				An issuer shall comply with section 1882(c)(3) of the Social Security Act (
				42
				U.S.C. §
										1395ss(c)(3),
				as enacted by section 4081(b)(2)(C) of the
Omnibus Budget
				Reconciliation Act of 1987 (OBRA) 1987
, Pub. L. No. 100-203) by:
(1) accepting a notice from a Medicare
				carrier on dually assigned claims submitted by participating physicians and
				suppliers as a claim for benefits in place of any other claim form otherwise
				required and making a payment determination on the basis of the information
				contained in that notice;
(2)
				notifying the participating physician or supplier and the beneficiary of the
				payment determination;
(3) paying
				the participating physician or supplier directly;
(4) furnishing, at the time of enrollment,
				each enrollee with a card listing the policy name, number and a central mailing
				address to which notices from a Medicare carrier may be sent;
(5) paying user fees for claim notices that
				are transmitted electronically or otherwise; and
(6) providing to the secretary, at least
				annually, a central mailing address to which all claims may be sent by Medicare
				carriers.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.20 - LOSS RATIO STANDARDS AND REFUND OR CREDIT OF PREMIUM

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Loss ratio standards.
(1)
Return of premiums.
(a) A Medicare Supplement policy form or
				certificate form shall not be delivered unless the policy form or certificate
				form can be expected, as estimated for the entire period for which rates are
				computed to provide coverage, i.e., are guaranteed, to return to policyholders
				and certificate holders in the form of aggregate benefits (not including
				anticipated refunds or credits) provided under the policy form or certificate
				form:
(i) At least seventy-five percent of the
				aggregate amount of premiums earned in the case of group policies; or
(ii) At least sixty-five percent of the
				aggregate amount of premiums earned in the case of individual
				policies;
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.21 - FILING AND APPROVAL OF POLICIES AND CERTIFICATES AND PREMIUM RATES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Filing
				policies and certificates.
An issuer shall not deliver or issue for
				delivery a policy or certificate to a resident of this state unless the policy
				form or certificate form has been filed and approved electronically in SERFF or
				as otherwise designated by the superintendent, pursuant to Subsection D of
				Section
				59A-17-9,
				Subsection D of Section
				59A-18-12
				and Subsection B of Section
				59A-18-13
				NMSA 1978.
B.
Filing riders
				and amendments.
An issuer shall file any riders or amendments to policy
				or certificate forms to delete outpatient prescription drug benefits as
				required by the
Medicare Prescription Drug, Improvement, and
				Modernization Act of 2003
only with the superintendent in the state in
				which the policy or certificate was issued.
C.
Filing rate change requests.
An issuer shall not use or change premium rates for a Medicare Supplement
				policy or certificate unless the rates, rating schedule and supporting
				documentation have been filed and approved electronically in SERFF or as
				otherwise designated by the superintendent, pursuant to Subsection D of Section
				59A-17-9,
				Subsection D of Section
				59A-18-12
				and Subsection B of Section
				59A-18-13
				NMSA 1978.
D.
Restrictions on
				number of forms filed.
(1) Except as
				provided in Paragraph (2) of this subsection, an issuer shall not file for
				approval more than one form of a policy or certificate of each combination of
				type and series for each standard Medicare Supplement benefit plan.
(2) An issuer may offer, with the approval of
				the superintendent, up to four additional policy forms or certificate forms of
				the same type for the same standard Medicare Supplement benefit plan, one for
				each of the following cases:
(a) The inclusion
				of new or innovative benefits;
(b)
				The addition of either direct response or agent marketing methods;
(c) The addition of either guaranteed issue
				or underwritten coverage;
(d) The
				offering of coverage to individuals eligible for Medicare by reason of
				disability.
(3) For the
				purposes of this subsection, a "type" means an individual policy, a group
				policy, an individual Medicare Select policy, or a group Medicare Select
				policy; "series" means the separate sets of 1990, 2010, and 2020 Standardized
				Medicare Supplement Benefit Plans defined in Sections 13.10.25.12, 13.10.25.14,
				and
				13.10.25.15
				NMAC respectively.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.22 - PERMITTED COMPENSATION ARRANGEMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
First year.
An issuer or
				other entity may provide commission or other compensation to an agent or other
				representative for the sale of a Medicare Supplement policy or certificate only
				if the first year commission or other first year compensation is no more than
				two-hundred percent of the commission or other compensation paid for selling or
				servicing the policy or certificate in the second year or period.
B.
Subsequent years.
The
				commission or other compensation provided in subsequent (renewal) years must be
				the same as that provided in the second year or period and must be provided for
				no fewer than five renewal years.
C.
Replacement policies.
No
				issuer or other entity shall provide compensation to its agents or other
				producers and no agent or producer shall receive compensation greater than the
				renewal compensation payable by the replacing issuer on renewal policies or
				certificates if an existing policy or certificate is replaced.
D.
Compensation defined.
For
				purposes of this section, "compensation" includes pecuniary or non-pecuniary
				remuneration of any kind relating to the sale or renewal of the policy or
				certificate including but not limited to bonuses, gifts, prizes, awards and
				finders fees.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.25 - FILING REQUIREMENTS FOR ADVERTISING

Current through Register Vol. 35, No. 13, July 16, 2024
An issuer shall provide a copy of any Medicare Supplement
				  advertisement intended for use in this state whether through written, radio or
				  television medium to the superintendent for review and approval electronically
				  in SERFF or as otherwise designated by the superintendent, pursuant to
				  Subsection D of Section
				  59A-17-9,
				  Subsection D of Section
				  59A-18-12
				  and Subsection B of Section
				  59A-18-13
				  NMSA 1978. Advertisements must comply with the requirements set forth in
				  13.10.4 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.26 - STANDARDS FOR MARKETING

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Issuer's procedures.
An issuer, directly or through its producers,
				shall:
(1) establish marketing procedures to
				assure that any comparison of policies by its agents or other producers will be
				fair and accurate;
(2) establish
				marketing procedures to assure excessive insurance is not sold or
				issued;
(3) display prominently by
				type, stamp or other appropriate means, on the first page of the policy the
				following: "Notice to buyer: This policy may not cover all of your medical
				expenses"
(4) inquire and otherwise
				make every reasonable effort to identify whether a prospective applicant or
				enrollee for Medicare Supplement insurance already has accident and sickness
				insurance and the types and amounts of any such insurance; and
(5) establish auditable procedures for
				verifying compliance with this Subsection A of this section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.27 - APPROPRIATENESS OF RECOMMENDED PURCHASE AND EXCESSIVE INSURANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Agent's
				responsibility.
In recommending the purchase or replacement of any
				Medicare Supplement policy or certificate an agent shall make reasonable
				efforts to determine the appropriateness of a recommended purchase or
				replacement.
B.
Duplicate
				policies prohibited.
Any sale of a Medicare Supplement policy or
				certificate that will provide an individual more than one Medicare Supplement
				policy or certificate is prohibited.
C.
Duplicate Part C prohibited.
An issuer shall not issue a Medicare Supplement policy or certificate to an
				individual enrolled in Medicare Part C unless the effective date of the
				coverage is after the termination date of the individual's Part C
				coverage.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.28 - REPORTING OF MULTIPLE POLICIES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Appendix B due date.
On or before March 1 of each year, an issuer
				shall report to the superintendent the following information for every
				individual resident of this state for which the issuer has in force more than
				one Medicare Supplement policy or certificate using the form referenced in
				Subsection B of 13.10.26.31 NMAC:
(1) policy
				and certificate number; and
(2)
				date of issuance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.29 - PROHIBITION AGAINST PREEXISTING CONDITIONS, WAITING PERIODS, ELIMINATION PERIODS AND PROBATIONARY PERIODS IN REPLACEMENT POLICIES OR CERTIFICATES

Current through Register Vol. 35, No. 13, July 16, 2024
A. If a Medicare
				Supplement policy or certificate replaces another Medicare Supplement policy or
				certificate, the replacing issuer shall waive any time periods applicable to
				preexisting conditions, waiting periods, elimination periods and probationary
				periods in the new Medicare Supplement policy or certificate to the extent such
				time was spent under the original policy.
B. If a Medicare Supplement policy or
				certificate replaces another Medicare Supplement policy or certificate which
				has been in effect for at least six months, the replacing policy shall not
				provide any time period applicable to preexisting conditions, waiting periods,
				elimination periods and probationary periods for benefits similar to those
				contained in the original policy or certificate.