reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.34 - FILING REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. An
				insurer 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 with and approved by the superintendent in accordance with filing
				requirements and procedures prescribed in Chapter 59A, Articles 18, 44, 46 and
				47 NMSA 1978. Policies and certificates of a master policy issued as a result
				of solicitations of individuals by agents, or through the mail or mass media
				advertising, including both print and broadcast advertising, shall be treated
				as individual policies for the purpose of this section.
B. An insurer shall not use or change premium
				rates for a long-term care policy or certificate unless the rating schedule and
				supporting documentation have been filed with and approved by the
				Superintendent in accordance with the filing requirements and procedures of
				this rule and Chapter 59A, Articles 18, 44, 46 and 47 NMSA 1978 in a form
				acceptable to the Superintendent.
C. An insurer or a similar organization
				offering group long-term care insurance to a resident of this state pursuant to
				Section 59A-23A-5 NMSA 1978 shall file with the Superintendent evidence that
				the group policy or certificate has been approved by a state having statutory
				or regulatory long-term care insurance requirements substantially similar to
				those adopted in this state.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.35 - EXEMPTION FROM LOSS RATIO REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Issuers of a life insurance policy that funds long-term care
				  benefits entirely by accelerating the death benefit are exempted from
				  13.10.15.32
				  NMAC if they provide to the Superintendent:
A. a statement that the interest credited to
				determine cash value accumulations, including long-term care, if any, are
				guaranteed to be not less than the minimum guaranteed interest rate for cash
				value accumulations without long-term care set forth in the policy.
B. a statement that the life insurance policy
				meets the requirements of the standard non-forfeiture law, Section
				59A-20-31NMSA 1978.
C. a statement
				that the life insurance policy reserves are set based upon Section 59A-8-5 NMSA
				1978.
D. a statement that the
				policy meets the disclosure requirements of this rule and Section 59A-23A NMSA
				1978.
E. a statement that any
				policy illustration used meets the requirements of rules adopted by the
				superintendent.
F. an actuarial
				memorandum which shall include:
(1) a
				description of the basis on which the long-term care rates were
				determined;
(2) a description of
				the basis for the reserves;
(3) a
				summary of the type of policy benefits, renewability, general marketing method
				and limits on ages of issuance;
(4)
				a description and a table of each actuarial assumption used. For expenses, an
				insurer must include percent of premium, dollars per policy and dollars per
				unit of benefits, if any;
(5) a
				description and a table of the anticipated policy reserves and additional
				reserves to be held in each future year for active lives; and
(6) the estimated average annual premium per
				policy and the average issue age;
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.36 - FILING REQUIREMENTS FOR ADVERTISING

Current through Register Vol. 35, No. 13, July 16, 2024
A. Every issuer shall provide a copy of any
				long-term care insurance advertisement intended for use in this state whether
				through written, radio or television medium to the Superintendent for review or
				approval by the Superintendent as required under Section 59A-23A-11 NMSA 1978.
				In addition, all advertisements shall be retained by the insurer, health care
				service plan or other entity for at least three (3) years from the date the
				advertisement was first used.
B.
				The Superintendent may exempt from these requirements any advertising form or
				material when, in the Superintendent's opinion, this requirement may not be
				reasonably applied.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.37 - STANDARDS FOR MARKETING

Current through Register Vol. 35, No. 13, July 16, 2024
Every insurer, health care service plan or other entity
				  marketing long-term care insurance coverage in this state, directly or through
				  its producers, shall:
A. establish
				marketing procedures and agent training requirements to assure that:
(1) any marketing activities, including any
				comparison of policies by its agents or other producers will be fair and
				accurate; and .
(2) excessive
				insurance is not sold or issued;
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.38 - PROHIBITED MARKETING PRACTICES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the practices prohibited in Chapter 59A,
				  Article 16 NMSA 1978, the following acts and practices are prohibited
A.
Twisting.
Knowingly making
				any misleading representation or incomplete or fraudulent comparison of any
				insurance policies or insurers for the purpose of inducing, or tending to
				induce, any person to lapse, forfeit, surrender, terminate, retain, pledge,
				assign, borrow on or convert any insurance policy or to take out a policy of
				insurance with another insurer.
B.
High pressure tactics.
Employing any method of marketing having
				the effect of or tending to induce the purchase of insurance through force,
				fright, threat, whether explicit or implied, or undue pressure to purchase or
				recommend the purchase of insurance.
C.
Cold lead advertising.
Making use directly or indirectly of any method of marketing which fails to
				disclose in a conspicuous manner that a purpose of the method of marketing is
				solicitation of insurance and that contact will be made by an insurance agent
				or insurance company.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.39 - ASSOCIATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The primary
				responsibility of an association endorsing or selling long-term care insurance
				shall be to educate its members concerning long-term care issues in general so
				that its members can make informed decisions. Associations shall provide
				objective information regarding long-term care insurance policies or
				certificates endorsed or sold by such associations to ensure that members of
				such associations receive a balanced and complete explanation of the features
				in the policies or certificates that are being endorsed or sold.
B. The insurer shall file with the
				Superintendent the following material:
(1)
				the policy and certificate as required herein,
(2) a corresponding outline of
				coverage,
(3) the premium rates as
				required herein, and
(4) all
				advertisements requested by the Superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.40 - SUITABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
This section shall not apply to life insurance policies that
				  accelerate benefits for long-term care.
A. Every issuer shall:
(1) develop and use suitability standards to
				determine whether the purchase or replacement of long-term care insurance is
				appropriate for the needs of the applicant;
(2) train its agents in the use of its
				suitability standards; and
(3)
				maintain a copy of its suitability standards and make them available for
				inspection upon request by the Superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.41 - REQUIREMENTS FOR LONG-TERM CARE INSURANCE PERSONAL WORKSHEETS

Current through Register Vol. 35, No. 13, July 16, 2024
A. To determine
				whether the applicant meets the standards developed by the issuer, the agent
				and issuer shall develop procedures that take the following into consideration:
(1) the ability to pay for the proposed
				coverage and other pertinent financial information related to the purchase of
				the coverage;
(2) the applicant's
				goals or needs with respect to long-term care and the advantages and
				disadvantages of insurance to meet these goals or needs; and
(3) the values, benefits and costs of the
				applicant's existing insurance, if any, when compared to the values, benefits
				and costs of the recommended purchase or replacement.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.42 - PROHIBITION AGAINST PREEXISTING CONDITIONS AND PROBATIONARY PERIODS IN REPLACEMENT POLICIES OR CERTIFICATES

Current through Register Vol. 35, No. 13, July 16, 2024
If a long-term care insurance policy or certificate replaces
				  another long-term care policy or certificate, the replacing insurer shall waive
				  any time periods applicable to preexisting conditions and probationary periods
				  in the new long-term care policy for similar benefits to the extent that
				  similar exclusions have been satisfied under the original
				  policy.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.43 - NONFORFEITURE BENEFIT REQUIREMENT

Current through Register Vol. 35, No. 13, July 16, 2024
This section does not apply to life insurance policies or
				  riders containing accelerated long-term care benefits.
A.
Offer required.
No policy or
				certificate may be delivered or issued for delivery in this state unless a
				policy or certificate providing for nonforfeiture benefits to the defaulting or
				lapsing policyholder or certificate holder has been offered to the applicant.
(1) A policy or certificate offered with
				nonforfeiture benefits shall have coverage elements, eligibility requirements,
				benefit triggers and benefit length that are the same as coverage offered
				without nonforfeiture benefits. The nonforfeiture benefit included in the offer
				shall be the benefit described in Subsection C of this section.
(2) The offer shall be in writing if the
				nonforfeiture benefit is not otherwise described in the outline of coverage or
				other materials given to the prospective policyholder.
(3) If the offer required to be made pursuant
				to this subsection is rejected, the insurer shall provide the contingent
				benefit upon lapse described in Subsection B of this section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.44 - STANDARDS FOR BENEFIT TRIGGERS

Current through Register Vol. 35, No. 13, July 16, 2024
The requirements of this section apply to all long-term care
				  insurance policies issued on or after January 1, 1999.
A. A long-term care insurance policy shall
				condition the payment of benefits on a determination of the insured's ability
				to perform activities of daily living and on cognitive impairment. Eligibility
				for the payment of benefits shall not be more restrictive than requiring either
				a deficiency in the ability to perform not more than three (3) of the
				activities of daily living or the presence of cognitive impairment.
B.
Activities of daily living.
(1) Activities of daily living shall include
				at least the following as defined in 13.10.15.8 NMAC and in the policy:
(a) bathing;
(b) continence;
(c) dressing;
(d) eating;
(e) toileting; and
(f) transferring.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.45 - CONTENTS OF OUTLINE OF COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. The outline of coverage shall be a
				free-standing document, using no smaller than ten point type.
B. The outline of coverage shall contain no
				material of an advertising nature.
C. Text which is capitalized or underscored
				in the standard format for outline of coverage provided in 13.10.15.46 NMAC may
				be emphasized by other means which provide prominence equivalent to such
				capitalization or underscoring.
D.
				Use of the text and sequence of text of the standard format for outline of
				coverage provided in 13.10.15.46 NMAC is mandatory, unless otherwise
				specifically indicated.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.47 - REQUIREMENT TO DELIVER SHOPPER'S GUIDE

Current through Register Vol. 35, No. 13, July 16, 2024
A. A long-term care insurance shopper's guide
				in the format developed by the National Association of Insurance Commissioners,
				or a guide developed or approved by the Superintendent, shall be provided to
				all prospective applicants of a long-term care insurance policy or certificate.
(1) In the case of agent solicitations, an
				agent must deliver the shopper's guide prior to the presentation of an
				application or enrollment form.
(2)
				In the case of direct response solicitations, the shopper's guide must be sent
				with any application or enrollment form.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.48 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any other penalties provided by the laws of
				  this state, any insurer and any agent found to have violated any requirement of
				  this state relating to the regulation of long-term care insurance or the
				  marketing of such insurance shall be subject to a fine of up to three (3) times
				  the amount of any commissions paid for each policy involved in the violation or
				  up to $10,000, whichever is greater.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.49 - APPENDIX A

Current through Register Vol. 35, No. 13, July 16, 2024
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
				  FOR THE STATE OF NEW MEXICO FOR THE REPORTING YEAR [ ]
Company Name:______________________________________
Address: ____________________________________________
____________________________________________
Phone Number:_______________________________________
Due: March 1 annually
INSTRUCTIONS
The purpose of this form is to report all rescissions of
				  long-term care insurance policies or certificates. Those rescissions
				  voluntarily effectuated by an insured are not required to be included in this
				  report. Please furnish one form per rescission.
Policy Form
Policy and Certificate Number
Name of Insured
Date of Policy Issuance
Date(s) Claim(s) Submitted
Date of Rescission
Detailed reason for rescission:
				  ____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
__________________________________
Signature
__________________________________
Name and Title (please type)
__________________________________
Date
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.51 - APPENDIX C

Current through Register Vol. 35, No. 13, July 16, 2024
THINGS YOU SHOULD KNOW BEFORE YOU BUY: LONG-TERM
						  CARE INSURANCE
Long-term Care Insurance
A long-term care
						  insurance policy may pay most of the costs for your care in a nursing home.
						  Many policies also pay for care at home or other community settings. Since
						  policies can vary in coverage, you should read this policy and make sure you
						  understand what it covers before you buy it. [You should
not
buy
						  this insurance policy unless you can afford to pay the premiums every year.]
						  The personal worksheet includes questions designed to help you and the company
						  determine whether this policy is suitable for your needs.
Medicare
Medicare does
not
pay for most long-term care.
Medicaid
Medicaid will generally pay for long-term care if you
						  have very little income and few assets. You probably should not buy this policy
						  if you are now eligible for Medicaid. Many people become eligible for Medicaid
						  after they have used up their own financial resources by paying for long-term
						  care services. When Medicaid pays your spouse's nursing home bills, you are
						  allowed to keep your house and furniture, a living allowance, and some of your
						  joint assets. Your choice of long-term care services may be limited if you are
						  receiving Medicaid. To learn more about Medicaid, contact your local or state
						  Medicaid agency.
Shopper's Guide
Make sure the insurance company
						  or agent gives you a copy of a book called National Association of Insurance
						  Commissioners" "Shopper's Guide to Long-Term Care Insurance." Read it
						  carefully. If you have decided to apply for long-term care insurance, you have
						  the right to return the policy within 30 days and get back any premium you have
						  paid if you are dissatisfied for any reason or choose not to purchase the
						  policy.
Counseling
Free counseling and additional information
						  about long-term care insurance are available through your state's insurance
						  counseling program. Contact your state insurance department or department on
						  aging for more information about the senior health insurance counseling program
						  in your state.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.52 - APPENDIX D

Current through Register Vol. 35, No. 13, July 16, 2024
LONG-TERM CARE INSURANCE SUITABILITY LETTER
Dear [Applicant]
Your recent application for long-term care
						  insurance included a personal worksheet which asked questions about your
						  finances and your reasons for buying long-term care insurance. For your
						  protection, state law requires us to consider this information when we review
						  your application, to avoid selling a policy to those who may not need coverage.
						  [Your answers indicate that long-term care insurance may not meet your
						  financial needs. We suggest that you review the information provided along with
						  your application, including the booklet "Shopper's Guide to Long-Term Care
						  Insurance" and the page titled "Things You Should Know Before Buying Long-Term
						  Care Insurance." Your state insurance department also has information about
						  long-term care insurance and may be able to refer you to a counselor free of
						  charge who can help you decide whether to buy this policy.] [You chose not to
						  provide any financial information for us to review.] We have suspended our
						  final review of your application. If, after careful consideration, you still
						  believe this policy is what you want, check the appropriate box below and
						  return this letter to us within the next 60 days. We will then continue
						  reviewing your application and issue a policy if you meet our medical
						  standards. If we do not hear from you within the next 60 days, we will close
						  your file and not issue you a policy. You should understand that you will not
						  have any coverage until we hear back from you, approve your application and
						  issue you a policy. Please check one box and return in the enclosed envelope.
						  ___
Yes
, [although my worksheet indicates that long-term care
						  insurance may not be a suitable purchase,] I wish to purchase this coverage.
						  Please resume review of my application. ___
No
, I have decided not
						  to buy a policy at this time. Signed: _________________________________
						  Applicant Date: __________________________
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. This rule
				applies to every:
(1) health insurance
				carrier, as defined in Paragraph (2) of Subsection C of Section
				59A-16-21.2
				NMSA 1978;
(2) vision and dental
				plans that use a provider network; and
(3) multiple employer welfare arrangement
				(individually a "carrier" and collectively "carriers").
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-16-21.1,
				  59A-23-14,
				  59A-46-54,
				  59A-47-49
				  and
				  59A-57-6
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to mandate provider grievance
				  processes that are fair, efficient and compliant with all applicable state and
				  federal laws, and to specify practices and procedures for external OSI review
				  of provider grievance appeals.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Terms used
				in this rule are as defined in Section 59A-22B-2 NMSA 1978 and in 13.10.29
				NMAC.
B. For the purposes of this
				rule, the subsequent term is supplemented and superseded as follows;
"Termination"
means the discontinuance of a provider's employment,
				contractual relationship or other business relationship with, and initiated by,
				a carrier.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.8 - GENERAL RULES

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier shall adopt and implement a provider grievance plan
				  that complies with this rule. This rule does not preclude a carrier and
				  provider from addressing or resolving a concern through any other process
				  agreed on between them, but no such alternative process shall preclude a
				  provider from presenting a grievance through a process that complies with this
				  rule.
A.
Allowed
				grievances.
At a minimum, a carrier's provider grievance plan shall
				allow a provider to present any concern regarding:
(1) credentialing deadlines;
(2) claim payment amount or timing;
(3) claim submission requirements or
				compliance;
(4) network adequacy,
				including participation determinations based on network composition;
(5) network composition including provider
				qualifications;
(6) utilization
				management practices;
(7) provider
				contract construction or compliance;
(8) patient care standards or access to
				care;
(9) surprise billing
				reimbursement amount, rate or timing;
(10) termination;
(11) operation of the plan including
				compliance with any law enforceable by the superintendent, or of any directive
				of the superintendent; or
(12)
				Discrimination.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.9 - PROVIDER TERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
For a grievance that concerns a termination a provider
				  grievance plan shall also comply with this section.
A.
Terminations for cause.
If a
				termination for cause, the provider grievance plan shall provide a fair hearing
				process that provides these minimum rights and protections:
(1) the right of the provider to appear in
				person at a hearing before the deciding panel;
(2) the right of the provider to present
				testimonial or documentary evidence at the hearing;
(3) the right of the provider to call
				witnesses, and cross-examine any witness;
(4) the right of the provider to be
				represented by an attorney or by any other person of the provider's
				choice;
(5) the right to an
				expedited hearing within 14 days of the termination in those instances where
				the carrier has not provided advance written notice of termination and the
				termination could result in imminent and significant harm to a covered
				person;
(6) a written decision
				within 20 days after the hearing, contemporaneously delivered via the
				provider's preferred method of communication; and
(7) if a group of providers is terminated for
				cause, each provider in the group shall have an individual right to a hearing.
				However, if any one of the providers in the group submits a grievance relating
				to the termination the carrier shall provide each similarly situated provider
				in the group with a notice of hearing, and each provider who receives such
				notice shall be bound by the carrier's determination subject to any appeal
				rights.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.10 - APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
At the request of a provider, the superintendent shall
				  conduct an external review of a provider grievance as authorized by this
				  section.
A.
Types of grievances
				subject to appeal.
The superintendent shall only review a provider
				grievance that pertains to:
(1) an alleged
				violation of a law enforceable by the superintendent;
(2) alleged noncompliance with an order of
				the superintendent; or
(3) a
				termination based on a provider's alleged failure to comply with a law or order
				enforceable by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.11 - RETALIATORY ACTION PROHIBITED

Current through Register Vol. 35, No. 13, July 16, 2024
No person shall be subject to retaliatory action by a carrier
				  for submitting or supporting a grievance or appeal.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.12 - PROVIDER MANUAL

Current through Register Vol. 35, No. 13, July 16, 2024
A carrier's provider manual shall include a clear statement
				  of a provider's right to grieve, the internal grievance process, the right of
				  appeal and the appeal process. The carrier shall publish its provider grievance
				  plan on a website accessible to any provider.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.13 - REPORTING AND COMPLIANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Provider
				grievance plan publication and changes.
No carrier shall publish a
				provider grievance plan., or any amendment of a provider grievance plan., that
				has not been reviewed and approved by the superintendent. A provider grievance
				plan shall be deemed approved if the superintendent fails to expressly approve,
				disapprove, or object to the provider grievance plan within 60 days from
				submission.
B.
Submission of
				provider grievance plan.
In conjunction with the provider contract
				certificate, a carrier shall submit a provider grievance plan for the
				superintendent's review and approval. At a minimum, the provider grievance plan
				shall include:
(1) a description of the
				procedures used by the carrier to receive, review, and respond to a provider
				grievance;
(2) the criteria and
				process the carrier uses to select the persons responsible for reviewing and
				responding to a provider grievance;
(3) the procedures by which the carrier's
				governing body is informed of provider grievances and the carrier's responses;
				and
(4) the title of staff
				responsible for implementation and oversight of the provider grievance
				process.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 16 - PROVIDER GRIEVANCES › Section 13.10.16.14 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any section of this rule, or the applicability of any
				  section to any person or circumstance, is for any reason held invalid by a
				  court of competent jurisdiction, the remainder of the rule, or the
				  applicability of such provisions to other persons or circumstances, shall not
				  be affected.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.2 - 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 health benefits plans, including health benefits
				plans:
(1) with a point-of-service option
				that allows subscribers to obtain health care services
				out-of-network;
(2) provided by an
				entity that purchases or is authorized to purchase health care benefits
				pursuant to the New Mexico Health Care Purchasing Act (Sections
				13-7-1
				through
				13-7-11
				NMSA 1978); and
(3) utilizing a
				preferred provider network, as defined under Section
				59A-22A-3 NMSA
				1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections
				  59A-1-16,
				  59A-2-8,
				  59A-2-9,
				  59A-15-16,
				  59A-16-3,
				  59A-16-11,
				  59A-16-12,
				  59A-16-12.1,
				  59A-16-20,
				  59A-16-22,
				  59A-19-4,
				  59A-19-6,
				  59A-22A-7,
				  59A-46-10,
				  59A-46-11,
				  59A-57-2,
				  59A-57-4,
				  and
				  59A-57-5
				  NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to establish procedures for
				  filing and processing adverse determination grievances and administrative
				  grievances regarding actions taken or inaction by a health care
				  insurer.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
As used in this rule:
A.
"Administrative decision"
means a decision made by a health care insurer regarding any aspect of a health
				benefits plan other than an adverse determination, including but not limited
				to:
(1) administrative practices of the
				health care insurer that affect the availability, delivery, or quality of
				health care services;
(2) claims
				payment, handling or reimbursement for health care services, including but not
				limited to complaints concerning co-payments, co-insurance and deductibles;
				and
(3) terminations of
				coverage.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.8 - COMPUTATION OF TIME

Current through Register Vol. 35, No. 13, July 16, 2024
Whenever this rule requires that an action be taken within a
				  certain period of time from receipt of a request or document, the request or
				  document shall be deemed to have been received within three days after the date
				  it was mailed.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.9 - GENERAL REQUIREMENTS REGARDING GRIEVANCE PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Written grievance procedures
				required.
Every health care insurer shall establish and maintain
				separate written procedures that comply with this rule to provide for the
				internal review of adverse determination grievances and administrative
				grievances.
B.
Divisible
				grievance.
If a grievance contains clearly divisible administrative and
				adverse determination issues, then the health care insurer shall initiate
				separate complaints for each issue with an explanation of the health care
				insurer's actions contained in one acknowledgment letter.
C.
Assistance to grievants.
In
				those instances, where a grievant requests or expresses interest in pursuing a
				grievance, the health care insurer shall assist the grievant to complete all
				the forms required to pursue internal review and shall advise grievant that the
				MHCB is available for assistance.
D.
Retaliatory action
				prohibited.
No person shall be subject to retaliatory action by the
				health care insurer for any reason related to a grievance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.10 - INFORMATION ABOUT GRIEVANCE PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
For covered
				persons/grievants.
A health care insurer shall:
(1) include a clear and concise summary of
				the grievance procedures, both internal and external, in boldface type in all
				handbooks or evidences of coverage, issued to covered persons, along with a
				link to the full version of the grievance procedures, as found on the OSI
				website;
(2) when the health care
				insurer makes either an initial or final adverse determination or an
				administrative decision, provide the following to a covered person, that
				person's authorized representative or a provider acting on behalf of a covered
				person:
(a) a concise written summary of its
				grievance procedures;
(b) a copy of
				the applicable grievance forms;
(c)
				a link to the full version of the grievance procedures, as found on the OSI
				website; and
(d) a toll-free
				telephone number, facsimile number, e-mail and mailing addresses of the health
				care insurer's consumer assistance office and for the MHCB.
(3) notify covered person that a
				representative of the health care insurer and the MHCB are available upon
				request to assist covered person with grievance procedures by including such
				information and a toll-free telephone number for obtaining such assistance in
				the enrollment materials and summary of benefits issued to covered
				person;
(4) make available on its
				website or upon request, consumer education brochures and materials developed
				and approved by the superintendent in consultation with the health care
				insurer;
(5) provide notice to
				covered person in a culturally and linguistically appropriate manner as defined
				in Subsection H of
				13.10.17.7
				NMAC;
(6) provide continued
				coverage for an approved on-going course of treatment pending the final
				determination on review;
(7) not
				reduce or terminate an approved on-going course of treatment without first
				notifying the grievant sufficiently in advance of the reduction or termination
				to allow a covered person to request a review and obtain a final determination
				on review of the proposed reduction or termination; and
(8) allow covered person in urgent care
				situations and those receiving an on-going course of treatment that the health
				care insurer seeks to reduce or terminate to proceed with an expedited IRO
				review at the same time as the internal review process.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.12 - NOTICE OF INITIAL DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
The notices required in Subsections A and B, of this section
				  shall be provided to the covered person, the covered person's authorized
				  representative, if applicable, and to a provider or other health care
				  professional with knowledge of the covered person's medical condition.
A.
Adverse determination.
(1) If an adverse determination is based on a
				determination that the requested service is experimental, investigational or
				not medically necessary, clearly and completely explain why the requested
				health care service is not medically necessary or is experimental or
				investigational; a statement that the health care service is not medically
				necessary, is experimental, or is investigational will not be
				sufficient.
(2) If an adverse
				determination is based on a lack of coverage, identify all health benefits plan
				provisions relied on in making the adverse determination, and clearly and
				completely explain why the requested health care service is not covered by any
				provision of the health benefits plan; a statement that the requested health
				care service is not covered by the health benefits plan will not be
				sufficient.
(3) If the service has
				already been provided, then include the date of service, the provider, the
				claim amount (if applicable), and a statement describing the availability, upon
				request, of the diagnosis code and its corresponding meaning, and the treatment
				code and its corresponding meaning.
(4) Include a description of the health care
				insurer's standard that was used in denying the claim.
(5) Provide information stating that a
				request for review of an adverse determination must be filed with the health
				care insurer within 180 days.
(6)
				If the adverse determination involves an urgent care situation, provide
				information that an expedited IRO review to be conducted at the same time as an
				expedited internal review may be requested.
(7) Describe the procedures and provide all
				necessary grievance forms for requesting internal review of the
				decision.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.13 - PRELIMINARY DETERMINATION OF GRIEVANCE

Current through Register Vol. 35, No. 13, July 16, 2024
Upon receipt of a grievance, a health care insurer shall
				  first determine the type of grievance at hand.
A. If the grievance seeks review of an
				adverse determination, it is an adverse determination grievance and the health
				care insurer shall review the grievance in accordance with its procedures for
				adverse determination grievances and the requirements of
				13.10.17.14
				NMAC through
				13.10.17.26
				NMAC 1978.
B. If the grievance is
				not based on an adverse determination, it is an administrative grievance and
				the health care insurer shall reconsider the decision in accordance with its
				procedures for administrative grievances and the requirements of
				13.10.17.27
				NMAC through
				13.10.17.33
				NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.14 - INTERNAL FIRST LEVEL REVIEW OF ADVERSE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Right to internal review.
Every grievant who is dissatisfied with an adverse determination shall have the
				right to request internal review of the adverse determination by the health
				care insurer within 180 days of the date of the adverse determination. Nothing
				in this rule precludes the health care insurer and grievant from resolving a
				request prior to completion of the internal review.
B.
Acknowledgement of request.
Upon receipt of a request for first level internal review of an adverse
				determination, the health care insurer shall date and time stamp the request,
				and within three days after receipt send the grievant an acknowledgment that
				the request has been received. The acknowledgment shall contain the name,
				address and direct telephone number of an individual representative of the
				health care insurer who may be contacted regarding the grievance.
C.
Full and fair internal
				review.
To ensure that a grievant receives a full and fair internal
				review, the health care insurer must:
(1)
				allow the grievant to review the claim file;
(2) allow the grievant to present evidence
				and submit evidence, including but not limited to written comments, documents,
				records and other materials relating to the request for benefits;
(3) as soon as possible but no less than five
				days in advance of the date of the internal review of adverse benefit
				determination, provide the grievant, free of charge, with:
(a) copies of all documents, policies,
				guidance, statements, records and other information relevant to the request for
				benefits; and
(b) all evidence or
				rationale, considered, relied upon, or generated by the health care
				insurer.
(4) allow the
				grievant a reasonable opportunity to respond before the adverse determination
				is reviewed and if the evidence or rationale is not provided to the grievant in
				time for the grievant to have a reasonable opportunity to respond, provide
				additional time at the grievant's request in order for the grievant to prepare
				a response.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.16 - INTERNAL PANEL REVIEW OF ADVERSE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability of internal panel
				review.
(1) A health care insurer that
				offers managed health care plans shall establish a panel review process for its
				managed health care plans to give those grievants who are dissatisfied with the
				internal review decision the option to request a panel review, at which the
				grievant has the right to appear in person before a panel of designated
				representatives of the health care insurer.
(2) This section also applies to persons
				covered under the New Mexico Health Care Purchasing Act (public employees and
				retirees, public school employees and retirees only).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.18 - ADDITIONAL REVIEW BY ENTITIES SUBJECT TO THE NEW MEXICO HEALTH CARE PURCHASING ACT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This section applies only to entities and grievants
				subject to the New Mexico Health Care Purchasing Act (public employees and
				retirees, public school employees and retirees only).
B.
Eligibility for review.
A
				grievant who remains dissatisfied with the decision of the health care insurer
				after the completion of the internal panel review must have their claim
				reviewed in accordance with any review process established by the entity
				providing their health care benefits pursuant to the New Mexico Health Care
				Purchasing Act.
C.
Decision
				to uphold.
If the health care insurer has upheld the initial adverse
				determination to deny the requested health care service at both the first level
				internal review and the internal panel review, the health care insurer shall
				notify the grievant that their grievance must be reviewed by their specific
				review board before their grievance may be eligible for an IRO review, as
				defined by their policy. The health care insurer shall ascertain whether the
				grievant wishes to pursue the grievance before the specific review board.
(1) If the grievant does not wish to pursue
				the grievance, the health care insurer shall include confirmation of the
				grievant's decision not to pursue the matter further with the written
				notification of the health care insurer's decision as described in Subsection B
				of
				13.10.17.17
				NMAC.
(2) If the health care
				insurer is unable to contact the grievant by telephone within one day of the
				panel's decision to uphold the adverse determination, the health care insurer
				shall send a written inquiry, as described in Subsection D of
				13.10.17.17
				NMAC.
(3) If the grievant responds
				affirmatively to the telephone or written inquiry the matter will proceed to a
				review by the grievant's specific review board, according to the procedures
				contained in the grievant's policy handbook.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 17 - GRIEVANCE PROCEDURES › Section 13.10.17.19 - IRO REVIEW OF AN ADVERSE DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Right to external IRO review.
Every grievant who is dissatisfied with an adverse determination following
				internal review of a grievance that involves medical judgment, including a
				determination based on medical necessity, appropriateness, health care setting,
				level of care, effectiveness or that the requested health care service is
				experimental, investigational or unproven for a particular medical condition
				may request an external review by an impartial IRO appointed by the
				superintendent at no cost to the grievant.
B.
Exhaustion of internal review
				process
. The superintendent may require the grievant to exhaust any
				required grievance procedures adopted by the health care insurer or the entity
				that purchases health care benefits pursuant to the New Mexico Health Care
				Purchasing Act, as appropriate, before accepting a grievance for IRO
				review.
C.
Deemed
				exhaustion.
If exhaustion of internal reviews is required prior to IRO
				review, exhaustion is unnecessary and the internal reviews process will be
				deemed exhausted if:
(1) the health care
				insurer waives the exhaustion requirement;
(2) the health care insurer is considered to
				have exhausted the internal review process by failing to comply with the
				requirements of the internal review process; or
(3) the grievant simultaneously requests an
				expedited internal review and an expedited IRO review.