reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.17 - FORM AND RATE FILING AND APPROVAL REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Prior
				approval of forms required
A carrier shall not issue, deliver or use a
				form associated with a plan, unless and until such form has been filed with and
				approved by the superintendent.
B.
Prior approval of rates required
A carrier shall not use rates or
				modified rates for an individual or group plan unless and until such rates are
				filed with and approved by the superintendent, except for rates for a plan
				issued to eligible members of an out-of-state group policyholder defined by
				Paragraph (1) of Subsection A of Section
				59A-23-3
				NMSA 1978. A carrier shall not offer a group coverage plan to New Mexico
				residents that are members of a group not defined in Paragraph (1) of
				Subsection A of Section
				59A-23-3
				NMSA 1978 under a plan issued to an out-of-state group policyholder unless the
				plan complies with Subsections D and G of this Section. Projected loss ratios
				for new plans or products shall be filed prior to sales and be based on
				credible data.
C.
Rate filing
				requirements
The superintendent shall post on its website requirements
				for filing actuarial memorandums and rates for rate filing requests.
D.
Minimum loss ratios for group
				plans
A group product subject to this rule shall be subject to the
				following actual minimum loss ratios, adjusted for low or high average premium
				forms:
(1)
Definitions of renewal
				clause.
The following definitions shall be applied to the table:
Type of Coverage:
OR
CR
GR
NC
Medical Expense
65%
60%
60%
55%
Loss of Income and Other
65%
60%
55%
50%
(a)
OR-
				Optionally Renewable
renewal is at the option of the insurance
				company;
(b)
CR- Conditionally
				Renewable
renewal can be declined by class; by geographic area or for
				stated reasons other than deterioration of health;
(c)
GR- Guaranteed Renewable
renewal cannot be declined by the insurance company for any reason, but the
				insurance company can revise rates on a class basis;
(d)
NC- Non-Cancelable
renewal
				cannot be declined nor can rates be revised by the insurance
				company.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.20 - COORDINATION OF BENEFITS, BUNDLING AND VARIABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Noncoordination of benefits
Benefits under a plan shall:
(1) be provided under a separate plan,
				certificate, or contract of insurance;
(2) have no coordination with the benefits
				offered under a health plan; and
(3)
				pay benefits regardless of any benefits provided under a health
				plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.21 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
The sale of any plan that does not comply with this rule is
				  unlawful. In addition to any applicable suspension, revocation or refusal to
				  continue any certificate of authority or license under the New Mexico Insurance
				  Code, a penalty for any material violation of this rule may be imposed against
				  a health care insurance carrier or insurance producer by the superintendent.
				  The actions of any producer or third-party administrator relating to the sale
				  of a plan subject to this rule, or a claim under any such plan, shall be deemed
				  the actions of the plan issuer.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.22 - 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 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.23 - PLANS SOLD TO INDIVIDUALS COVERED UNDER MAJOR MEDICAL INSURANCE

Current through Register Vol. 35, No. 13, July 16, 2024
Accident-only, specified disease or illness, hospital
				  indemnity, and other fixed indemnity plans issued to individuals, employer
				  groups, labor unions or group plans issued through bona fide associations,
				  covered under a major medical plan shall comply with the provisions of this
				  section.
A.
Proof of coverage
				required
. Carriers must obtain proof of major medical coverage prior to
				the issuance of a plan subject to this section. Proof shall be demonstrated
				through:
(1)
Individual plans
:
(a) A copy of the current insurance card;
				or
(b) the insurer name, group, and
				policy number.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.24 - CONTINUING EDUCATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
License required
. All producers selling excepted benefits plans
				under this rule must maintain current licensure with the state in accordance
				with the New Mexico Insurance Code.
B.
Continuing education
.
				Producers transacting in excepted benefits must complete at least two hours in
				specialized training in excepted benefits in order to meet continuing education
				requirements found in 13.4.7 NMAC.
C.
Course offering
. Carriers
				offering excepted benefits for sale in New Mexico must offer two-hour
				specialized training courses for producers. Courses shall comply with all
				provisions of 13.4.7 NMAC.
D.
Effective date
. The requirements of this section shall go into
				effect on April 1, 2026 or upon the final adoption of the amended rule at
				13.4.7 NMAC, whichever is later. Licensees, defined under
				13.4.7.7 NMAC and subject to this
				rule, must comply with its requirements prior to the next compliance
				period.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to every carrier who offers or sells any
				  individual or group dental or vision insurance plan ("plan") separately from a
				  health benefits plan, whether on or off the exchange. This rule does not apply
				  to any pediatric dental or vision plan, or to any prepaid dental plan. Subject
				  to the foregoing, this rule applies to a group dental or vision plan offered or
				  sold to a New Mexico resident under a master policy delivered outside of this
				  state.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-2-9,
				  59A-23F-7, and
				  59A-23G-1 et seq. NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2022 unless a later date is cited at the end of a
				  section. If the superintendent previously approved a subject plan, that plan
				  shall comply with this rule no later than January 1, 2022, if issued on or
				  after that date.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
Establish minimum regulatory standards and sales practices
				  relating to dental and vision plans; standardize and simplify the terms and
				  coverages; facilitate public understanding and comparison of coverage;
				  eliminate provisions that may be misleading or confusing in connection with the
				  purchase and renewal of the coverages or with the settlement of claims; and
				  require disclosures in the marketing and sale of the subject
				  plans.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For definitions of terms contained in this rule, refer to
				  13.10.29 NMAC, unless otherwise noted below.
A.
"Domestic co-insured"
means a
				spouse or domestic partner insured under the same plan or
				certificate.
B.
"Earned
				premiums"
for a reporting year means the premium received up to the loss
				ratio measurement date that provided coverage during that reporting
				year.
C.
"Incurred
				claims"
for a reporting year means the claims for which services were
				provided in the reporting year. This includes such claims that were paid in the
				reporting year plus unpaid claims reserves for such reporting year.
D.
"Loss ratio"
means the
				incurred claims divided by earned premiums, calculated pursuant to Subsection D
				of 13.10.35.9 NMAC.
E.
"Loss ratio measurement date"
means the date as of which the incurred claims and earned premiums for each
				reporting year are determined for the reporting required in Subsection M of
				13.10.35.9 NMAC of this
				rule.
F.
"Preferred
				provider"
means a dental or vision care provider, or group of providers,
				who contracts with a dental or vision insurance carrier to provide dental or
				vision services to a covered person.
G.
"Reporting year"
means a
				calendar year during which group or individual dental coverage is provided by a
				policy, contract or certificate covering dental services.
H.
"Schedule of benefits"
means
				any form that is part of an insurance policy filed with and approved by the
				superintendent that contains any of the following information: coverage levels,
				cost sharing features, covered services, benefit maximums and exclusions.
I.
"Unpaid claim
				reserves"
for a reporting year means reserves and liabilities
				established as of the applicable loss ratio reporting year but were paid after
				the reporting year.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.8 - GENERAL PROHIBITED POLICY PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Probationary and waiting periods.
Except as otherwise expressly
				allowed under Sections 10 and 11 of this rule, a plan shall not include any
				probationary or waiting period during which no coverage is provided for a
				covered benefit, except an eligibility waiting period during which no premium
				is paid.
B.
Riders and other
				supplements.
Any rider, amendment, endorsement or other supplement shall
				explicitly state which terms of coverage the carrier has amended or
				supplemented from the original plan.
C.
Exclusions
. A plan that
				includes any exclusions shall comply with these requirements:
(1) each plan application shall include a
				prominent notice that the plan includes a preexisting exclusion, and display
				either the full text of the exclusion or directions as to how to obtain a copy
				of that text.
(2) the carrier shall
				not enforce a preexisting condition exclusion if an enrollee renews coverage
				under a plan offered by the same carrier.
(3) a plan application shall not request
				family member health information unless the family member is also seeking
				coverage under the plan; and
(4) a
				plan may exclude benefits for the replacement of a tooth that the covered
				person lost prior to the covered person's plan effective date unless the
				covered person had coverage from a prior carrier.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.9 - GENERAL STANDARDS FOR POLICIES AND BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
For
				individual plans.
The following general standards apply to individual
				plans.
(1) An individual plan shall have a
				minimum term of 12 months.
(2) A
				"noncancellable," "guaranteed renewable," or "noncancellable and guaranteed
				renewable" individual plan shall not provide for termination of coverage of the
				domestic co-insured solely because of the occurrence of an event specified for
				termination of coverage of the covered person, other than nonpayment of
				premium. In addition, the plan shall provide that in the event of the covered
				person's death, the domestic co-insured of the covered person, if covered under
				the plan, shall become a covered person with the issuance of a new policy and
				completed agreement.
(3) An
				individual plan shall protect consumer rights as follows:
(a) The terms "noncancellable" or
				"noncancellable and guaranteed renewable" may only be used in an individual
				dental or vision plan if the covered person has the right to continue the
				coverage by timely paying premiums, until the age of 65 or until eligibility
				for Medicare, whichever is later, during which time the carrier has no
				unilateral right to change any provision of the plan.
(b) The term "guaranteed renewable" may only
				be used in a plan where the covered person has the right to continue in force,
				by timely paying premiums, until the age of 65 or until eligibility for
				Medicare, whichever is later, during which period the carrier has no unilateral
				right to change any provision of the plan, other than changes in premium rates
				by classes.
(c) A plan shall not
				terminate the coverage of a covered person except for "good cause," as follows:
(i) failure of the covered person or
				subscriber to pay the premiums and other applicable charges for
				coverage;
(ii) material failure to
				abide by the rules, policies or procedures of the plan;
(iii) fraud or misrepresentation affecting
				coverage;
(iv) policyholder request
				for cancellation;
(v) policy term
				ends; or
(vi) a reason for
				termination or failure to renew that the superintendent determines is not
				objectionable.
(4) If an individual plan covers domestic
				co-insureds, the age of the younger insured shall be used as the basis for
				meeting the age and durational requirements of the definitions of
				"noncancellable" or "guaranteed renewable." However, this requirement shall not
				prevent termination of coverage of the older insured upon attainment of the
				stated age so long as the policy may be continued in force as to the younger
				spouse to the age or for the durational period specified in the
				policy.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.10 - DENTAL PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability
. This section applies only to subject dental
				plans.
B.
Definitions.
For purposes of this Section:
(1) "Dental
				plan" is a policy, contract, agreement or arrangement under which an entity
				undertakes to reimburse claims for the cost of dental services and dental
				supplies.
(2) "Dental service"
				means a professional service rendered by a person duly licensed under the laws
				of this state to practice dentistry or dental therapy, or dental hygienists or
				dental hygienists certified in collaborative practice and any service
				constituting the practice of dentistry under state law.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.11 - VISION PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability
. This section only applies to subject vision
				plans.
B.
Definitions
.
				For purposes of this section:
(1) "covered
				materials" means materials that are reimbursable by a vision plan to a vision
				care provider subject to any deductible, copayment, coinsurance, or other plan
				limitation;
(2) "covered services"
				means services that are reimbursable by a vision plan vision plan to a vision
				care provider subject to any deductible, copayment, coinsurance, or other plan
				limitation;
(3) "materials" means
				ophthalmic devices, including;
(a)
				lenses;
(b) frames;
(c) contact lenses; and
(d) spectacle or contact lens treatments and
				coatings;
(4)
				"noncovered materials" means materials that are not covered by a vision
				plan;
(5) "noncovered services"
				means services that are not covered by a vision plan.
(6) "vision services" means services provided
				by a vision care provider;
(7)
				"vision plan" is a policy, contract, agreement or arrangement under which an
				entity undertakes to reimburse claims for the cost of vision services or vision
				materials; and
(8) "vision care
				provider" means an individual licensed under state law as an optometrist or
				ophthalmologist.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.12 - COORDINATION AND COMBINATION OF BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A dental or vision plan shall only
				coordinate or combine benefits as permitted under state or federal law and as
				specified in the plan.
B. A carrier
				and plan that offers both dental and vision benefits is subject to both the
				dental and vision provisions of this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.13 - COVERAGE DOCUMENTATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Coverage forms and benefits disclosures.
(1) A carrier shall issue a policy,
				certificate of coverage or summary of benefits to each covered person on or
				before the effective date of coverage or of a change in coverage. Covered
				groups may distribute a certificate of coverage or summary of benefits on
				behalf of the carrier.
(2) The
				policy, certificate of coverage or schedule of benefits shall include a clear
				and complete statement of:
(a) the covered
				services, supplies and materials;
(b) any limitations or exclusions including
				any charge, deductible or copayment feature;
(c) cost-sharing features must be written
				from the perspective of the insured;
(d) where and in what manner information is
				available and as to how services may be obtained;
(e) a clear and understandable description of
				the method for resolving a covered person's complaint;
(f) a reinstatement provision which states
				that when premium is not paid within the applicable grace period, a subsequent
				acceptance of premium by the insurer or their agent without requiring an
				application for reinstatement, shall reinstate the policy. However, if the
				insurance company requires an application for reinstatement and issues a
				conditional receipt for the premium tendered, the policy will be reinstated
				upon approval of such application, lacking such approval, upon the 30th day
				following the date of such conditional receipt unless the insurance company has
				previously notified the insured in writing of its disapproval of such
				application;
(g) a clear and
				understandable description of the conditions for renewal;
(h) procedures for filing claims;
(i) statement of the amounts payable to the
				carrier by a covered person and the times at which the amounts shall be
				paid;
(j) the period during which
				the plan is effective; and
(k) on
				the front page, the identity of the carrier.
(3) Any subsequent change in coverage or
				premium shall be explained in a separate document delivered to the covered
				person.
(4) PPO and indemnity plans
				cannot be combined and must be submitted in separate product filings.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.14 - NETWORK ADEQUACY

Current through Register Vol. 35, No. 13, July 16, 2024
Each dental or vision plan that in any way conditions
				  coverage on the provision of services by a preferred provider shall maintain an
				  adequate network of such providers:
A.
Attestation.
A carrier shall submit to the superintendent annually
				an attestation of compliance with all of the criteria of this section by
				October 1, 2022 and every year thereafter.
(1) That, in population areas of 50,000 or
				more residents, two dental or vision care providers are available in any county
				within no more than 20 miles or 20 minutes' average driving time for ninety
				percent of the enrolled population, or, in population areas of less than
				50,000, whether two dental or vision care providers are available in any county
				or service area within no more than 60 miles or 60 minutes' average driving
				time for ninety percent of the enrolled population. For remote rural areas, the
				superintendent shall consider on a case by case basis whether the dental or
				vision plan has made sufficient providers available given the number of
				residents in the county or service area and given the community's standard of
				care.
(2) That the dental or vision
				plan provides reasonable and reliable access for its covered persons to
				qualified health care professionals in those specialties that are covered by
				the dental or vision plan.
(3) Any
				major deficiencies in the dental or vision plan's provider network and a
				description of current activities to remedy network deficiencies.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.15 - UTILIZATION MANAGEMENT DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Denial of services.
A benefit
				denial that is based on a determination that a dental or vision service is not
				medically necessary, and that is the result of a formal prior authorization
				review process, shall be supported by a contemporaneous opinion of a provider
				licensed to provide the requested service. Any such determination shall be made
				in accordance with medical necessity standards and appropriate clinical
				guidelines.
B.
Pretreatment
				Estimates.
A carrier may issue a non-binding pretreatment estimate for
				the coverage and reimbursement of proposed dental or vision services. A
				pretreatment estimate does not determine medical necessity and does not serve
				as a prior authorization.
(1) A pretreatment
				estimate shall include a statement that clearly indicates to the covered person
				that the estimate is not a guarantee of coverage.
(2) A pretreatment estimate shall clearly
				identify the services that require an approved prior authorization for coverage
				and shall include a statement that the covered person may be liable for the
				full cost of the service if an approved prior authorization is not
				obtained.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.16 - CONSUMER COMPLAINTS

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier shall state in all plan documents that a covered
				  person who cannot resolve a complaint with the plan may contact the office of
				  the superintendent of insurance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.17 - 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 insurance carrier 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 35 - Minimum Standards for Dental and Vision Plans › Section 13.10.35.18 - 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 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Office of Superintendent of Insurance
				  ("OSI").
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules govern the establishment and provision of a
				  Health Care Affordability Plan and administration of the Health Care
				  Affordability Fund (the "Fund").
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Section 59A-23F-12 NMSA 1978 (the "Health Care Affordability
				  Plan").
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.4 - DURATION

Current through Register Vol. 35, No. 13, July 16, 2024
Permanent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
May 1, 2022, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules establish policies, procedures, and controls for
				  the establishment and maintenance of a
"Health Care Affordability
				  Plan"
as funded by the
"Health Care Affordability
				  Fund"
to achieve the public policy purposes in the manner prescribed
				  under Sections 59A-23F-11 and 59A-23F-12 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.8 - APPROPRIATIONS REQUESTS

Current through Register Vol. 35, No. 13, July 16, 2024
This rule governs appropriation requests.
A. Annually, the superintendent will submit
				appropriation requests to the legislative finance committee for each fund
				program. OSI will post proposed program parameters associated with the budget
				request on the agency's website upon submission to the legislative finance
				committee.
B. The request for each
				fund program shall meet these minimum standards:
(1) for the marketplace affordability
				program, sufficient funding to provide premium reductions for individuals under
				four hundred percent of the FPL and OOP cost reductions for individuals under
				three hundred percent of the FPL;
(2) for the small business health insurance
				premium relief initiative, sufficient funding to realize premium reductions for
				qualified health plans across the small group market; and
(3) for the uninsured program, sufficient
				funding to expand coverage to eligible individuals under two hundred percent of
				the FPL before expanding further up the income scale.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.9 - PREMIUM ASSISTANCE AND ANNUAL OOP PROGRAMS

Current through Register Vol. 35, No. 13, July 16, 2024
This rule governs the annual state out-of-pocket assistance
				  and premium assistance programs.
A.
Affordability criteria:
Annually, the superintendent shall publish
				a bulletin specifying affordability criteria for the ensuing plan year. Absent
				extenuating circumstances that mandate an earlier rate filing, the
				superintendent shall allow issuers at least 15 days from publication of the
				bulletin to make an initial QHP rate filing. If the federal government changes
				policies that will affect the cost of the program to the state or the cost to
				enrollees after the issuance of the bulletin, the superintendent may adjust the
				affordability criteria.
(1) These are the
				affordability criteria that the superintendent may consider to determine
				premium assistance eligibility for a plan year. The superintendent will use
				these criteria to establish a premium sliding scale based on household income:
(a) the percentage of an enrollee's MAGI as
				computed according to federal standards;
(b) the percentage of enrollee's MAGI that
				would be needed to purchase the state benchmark plan as established by the
				superintendent;
(c) the percentage
				of New Mexico residents at or below a given the FPL percentage; and
(d) The federal premium sliding scale for
				marketplace coverage.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 36 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.36.10 - MINIMIZING COVERAGE DISRUPTIONS AFTER THE FEDERAL MEDICAID CONTINUOUS COVERAGE REQUIREMENT EXPIRES

Current through Register Vol. 35, No. 13, July 16, 2024
This rule governs the agency's efforts to ensure a smooth
				  transition into a QHP offered on the New Mexico health insurance exchange for
				  individuals who no longer qualify for medicaid after the expiration continuous
				  coverage requirement in the federal "families first coronavirus response
				  act".
A.
Temporary medicaid
				transition premium relief program.
The superintendent may issue a
				bulletin establishing a program that fully covers the cost of the first month's
				premium for any QHP sold on the individual health insurance exchange for
				eligible individuals and families. The premium relief will be available to all
				members of a household that meet the eligibility requirements in Paragraph B of
				this section. The payment may be used to effectuate coverage.
B.
Eligibility for medicaid
				transition premium relief program.
To qualify, a person must:
(1) be a resident of the state of New Mexico
				who is eligible to purchase a QHP on the New Mexico health insurance
				exchange;
(2) have lost medicaid
				coverage or expect to lose medicaid coverage within 60 days of submitting an
				application to the New Mexico health insurance exchange;
(3) no longer be enrolled in medicaid at the
				time their QHP coverage begins;
(4)
				be eligible for federal premium tax credits; and
(5) have an expected household income below
				four hundred percent of the federal poverty level during the plan year in which
				the federal coronavirus disease (COVID-19) public health emergency ends
				.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to health care facilities, third-party
				  health care providers, medical creditors, medical debt collectors and medical
				  debt buyers subject to Sections 57-32-1 to 57-32-10 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-2-9
				  NMSA 1978 and sections 57-32-1 to 57-32-10 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
To ensure that health care facilities offer and provide
				  screenings to uninsured patients who may be eligible for Medicaid or other
				  public health insurance, and to ensure that medical debt incurred by indigent
				  patients will not be pursued through certain proscribed collection
				  actions.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For definitions of terms contained in this rule, refer to the
				  Patients' Debt Collection Protection Act Sections 57-32-1 to 57-32-10 NMSA 1978
				  and in Chapter 59A NMSA 1978, unless otherwise noted below.
A.
"Culturally and linguistically
				appropriate
" means communication that meets the following requirements:
(1) the provision 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 American sign language (ASL), and providing assistance with
				filing claims and reviews in any applicable non-English language;
(2) the provisions of, upon request, verbal
				interpretation or translation of a notice into 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 facility;
(4) applicable non-English language is as
				defined by the centers for Medicare and Medicaid Services; and
(5) any written notice required by this rule
				must include the required information in English and Spanish.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.8 - SCREENING FOR INSURANCE AND PROGRAM ELIGIBILITY

Current through Register Vol. 35, No. 13, July 16, 2024
A health care facility shall screen all patients and offer to
				  assist uninsured patients in obtaining or accessing Medicaid, public insurance,
				  public programs that assist with health care costs, and other financial
				  assistance offered by the health care facility, before seeking payment for
				  emergency or medically necessary care. A health care facility shall include a
				  written notification regarding screening with any forms presented to patients
				  for completion prior to service. No collection action shall occur during the
				  screening process or while the patient's financial status or application for
				  insurance or financial assistance is under review or in process. During a
				  screening or provision of application assistance under this section, a health
				  care facility shall not request or require information or documentation that is
				  not necessary to determine eligibility for public insurance, public programs
				  that may assist with health care costs, or financial assistance.
A.
Timing.
Health care
				facilities shall affirmatively offer to screen patients and, if the patient
				accepts the offer, 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 48 hours of admission;
(c) a
				patient who receives outpatient care shall be screened at the time that the
				outpatient care is scheduled or prior to completion of treatment;
(d) upon request of a patient who is
				scheduled to receive or has received health care services from the health care
				facility; or
(e) an incapacitated
				patient, including unconscious or otherwise unable to communicate, shall be
				screened when the patient is able to effectively communicate, if such status is
				achieved prior to discharge. The health care facility shall offer screening to
				parents, spouses, persons with healthcare powers of attorney or guardians of
				the patient, on the incapacitated patient's behalf.
(f) screening shall be provided upon request
				and shall be offered at least once for every episode of care within a 12 month
				period of time;
(g) completion of
				the screening process may occur outside of the specified time frames if the
				facility has made a documented good faith effort to complete the screening
				timely but is unable to do so due to availability of its screening personnel,
				inability of the patient to provide necessary documentation, or lack of
				cooperation of the patient.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 39 - PATIENTS' DEBT COLLECTION PROTECTIONS › Section 13.10.39.9 - INDIGENT PATIENT DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
Collection action based on charges for health care services
				  and medical debt may not be pursued against an indigent patient. A
				  determination whether a patient is an indigent patient shall be made before
				  collection action is pursued against the patient.
A.
Prohibited activity.
Medical
				creditors and medical debt collectors shall not pursue collection action
				against indigent patients.
(a) A medical
				creditor may engage in a determination of indigency at the time of service or
				at any time during or after the provision of services. If the patient is
				determined to be indigent the medical creditor may not engage in prohibited
				collection action.
(b) A failure to
				make a determination of indigency does not waive the prohibition on collection
				action against indigent patients unless the failure to make the determination
				is due to noncooperation by the patient. Noncooperation must be documented and
				the medical creditor or debt collector must be able to demonstrate a minimum of
				three efforts to contact the patient.
(c) Any bill or statement to a patient must
				be accompanied by a notice, in English and Spanish, in at least 14-point font
				in the form prescribed by the superintendent. The superintendent will publish
				the required notice on its website.
(d) If the patient contacts the medical
				creditor or medical debt collector to request a determination of indigency, the
				medical creditor or medical debt collector must make a determination using the
				methodology set forth below.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
These rules apply to every "health insurer" and "group health
				  plan," as defined in the Vaccine Purchasing Act ("VPA"), who are providing
				  coverage to residents of New Mexico, regardless of location of the policy, and
				  are therefore subject to compliance obligations under Sections
				  24-5A-1
				  through
				  24-5A-9
				  NMSA 1978. For purposes of this rule, a multiple employer welfare arrangement
				  as defined in Section
				  59A-1-8.1
				  NMSA 1978 is considered a "health insurer" subject to the
				  VPA.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
All definitions of terms found in Section
				  24-5A-2
				  NMSA 1978 are incorporated herein as though stated fully. The following
				  definitions apply to this rule only:
A.
"covered employer"
means any employer who offers group health
				insurance coverage to a resident of New Mexico through a group health plan or
				policy issued by a health insurer; and
B.
"day" or "days"
shall be
				calculated as follows, unless otherwise specified:
(1) one to 10 days means only working days
				and excludes weekends and state holidays; and
(2) 11 or more days means calendar days,
				including weekends and state holidays.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.8 - REPORTING AND PAYMENT REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
As directed in these rules, every health insurer and group
				  health plan shall annually report to the superintendent the number of insured
				  children who are residents of New Mexico under each policy and plan, who were
				  under the age of 19 as of the previous December
				  31st, even if that number is zero.
A.
Report deadline.
The required
				report is due by the date established by the superintendent, but no later than
				July 31st of each year.
(1) The superintendent may extend the
				deadline for good cause. A reporter must file a request for an extension, with
				the reason for the request, at least five days before the report is
				due.
(2) Failure to report by this
				deadline shall result in a $500 a day penalty pursuant to Subsection B of
				Section
				24-5A-7 NMSA
				1978. The superintendent shall issue written notice of failure to submit a
				timely report which specifies the statutory penalty to the designated contact
				person for each health insurer or group health plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.9 - BILLING AND ENFORCEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Billing
				cycle.
The department shall send out the invoices to each health insurer
				and each group health plan for one-fourth of its proportionate share of the
				estimated amount and reserve calculated pursuant to Subsection B of this
				Section, as required by Subsection D of Section 25-5A-3 NMSA 1978, according to
				the following billing cycle:
Billing Cycle
Department's Invoices
								Date
Insurer's and Group Health
								Plan's Due Date
July 1 to September 30
September 1
October 1
October 1 to December 31
December 1
January 1
January 1 to March 31
March 1
April 1
April 1 to June 30
June 1
July 1
B.
Payment.
A health insurer or group health plan shall remit payment
				to the department's fiscal agent in the manner directed by the department in
				the invoice, with a corresponding notification of remittance to
				vpa.fund@state.nm.us.
(1) The annual amount to
				be reimbursed by each health insurer or group health plan shall be a fraction,
				the denominator of which is the total number of insured children reported by
				all health insurers and group health plans and the numerator of which is the
				number of insured children reported by such health insurer or group health
				plan, multiplied by the total amount as determined by the department to be
				expended annually in the corresponding year.
(2) Failure to remit payment within 30 days
				receipt of the invoice will result in the issuance of a penalty pursuant to
				Subsection D of Section
				24-5A-7 NMSA
				1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.10 - PUBLICATION

Current through Register Vol. 35, No. 13, July 16, 2024
The superintendent shall, by January
				  31st of each calendar year, make publicly available
				  on their website, a comprehensive list of all health insurers and group health
				  plans that a) maintained compliance with the VPA in the preceding year, b)
				  failed to comply with reporting requirements under the VPA, and c) failed to
				  make timely payments under the VPA.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.11 - ACCOUNTING OF THE FUND

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Expenditures.
Money in the fund shall be expended only for the
				purposes specified in the VPA, by warrant issued by the secretary of finance
				and administration pursuant to vouchers approved by the secretary of
				health.
B.
Audit.
The
				fund shall be audited in the same manner as other state funds are audited, and
				all records of payments made from the fund shall be open to the
				public.
C.
Balance.
Any balance remaining in the fund shall not revert or be transferred to any
				other fund at the end of a fiscal year.
D.
Investment.
Money in the fund
				shall be invested by the state investment officer in accordance with the
				limitations in Article 12 Section 7 of the constitution of New Mexico. Income
				from investment of the fund shall be credited to the fund.
E.
Estimate.
July 1 of each year
				thereafter, the department shall estimate the amount to be expended annually by
				the department to purchase, store, and distribute vaccines recommended by the
				advisory committee on immunization practices to all insured children in the
				state, including a reserve of ten percent of the amount estimated.
F.
Update.
The department may
				update its estimated amount to be expended annually and its reserve to take
				into account increases or decreases in the cost of vaccines or the costs of
				additional vaccines that the department determines should be included in the
				statewide vaccine purchasing program and adjust the amount invoiced to each
				health insurer and group health plan the following quarter.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 40 - VACCINE PURCHASING FUND › Section 13.10.40.12 - 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. There shall be no
				  right to hearing by the department.