New Mexico Administrative Code

Permanent.

November 30, 1998, unless a later date is cited at the end of a section.

The purpose of this rule is to implement the Medical Insurance Pool Act, Chapter 59A, Article 54 NMSA 1978.

In addition to the definitions in Section 59A-54-3 NMSA 1978, as used in this rule: A. Act means the Medical Insurance Pool Act, Chapter 59A, Article 54 NMSA 1978. B. plan or plan of operation means this rule.

A. All insurers admitted in New Mexico as of June 19, 1987 shall be members of this pool. Each insurer admitted after June 19, 1987 shall automatically become a member of the pool on the date of its admission. An insurer which ceases to be admitted after June 19, 1987 shall autom…

A. Appointed members. The superintendent shall announce his appointments to the board at the annual membership meeting. B. Elected members. (1) Prior to the annual membership meeting, members shall be contacted by mail by the administrator, or as otherwise directed by the board, …

New Mexico Public Regulation Commission, Insurance Division.

A. The officers of the board will be the chair of the board, a vice chair, and a secretary, and such other officers as the board may decide, who, except for the chair, will be elected annually by the board at its annual meeting to serve until their successors are elected and qual…

A. The board shall have the standing committees set forth below. Members of the committees shall be named by and serve at the pleasure of the chair. In addition to the authority specified, the committees shall have such duties and responsibilities as may be delegated to them from…

A. The board, in addition to the powers prescribed in the act, shall have the specific authority to enter into contracts and undertake such other activities as are necessary or proper to carry out the provisions and purposes of the act, including the authority, with the approval …

No contract or transaction between the alliance and one or more of its directors, or between the alliance and any other corporation, partnership, association or other organization in which one or more if its directors are directors or officers, or have a financial interest, shall…

A. The fiscal year of the alliance shall be determined by the board. B. The board of directors shall conduct periodic audits to assure the general accuracy of the financial data submitted to the alliance pursuant to Section 59A-56-11 NMSA 1978. The board shall cause the alliance …

The alliance may pay referral or servicing fees or commissions subject to applicable provisions in the Insurance Code, or may require carriers to pay a commission to the insurance agent who refers an applicant to the alliance if that applicant is accepted. No agent shall be eligi…

A. All persons, except the superintendent and his staff, described in the act shall be indemnified by the alliance for all expenses incurred in the defense of any action, suit or proceeding brought against such person on account of any action taken by him in the performance of hi…

In the event an insured, an agent, a group or a member believes the performance of the alliance or a member does not meet its expectations or conform to a policy or plan issued by a member through the alliance, that person may bring the matter to the attention of the alliance by …

The plan of operation may be altered, amended, or repealed by a two-thirds vote of directors elected or appointed, and approval of such action by the superintendent.

A. The eligibility criteria in 13.10.11.20 NMAC through 13.10.11.33 NMAC apply to approved health plans for small employers; the eligibility criteria in 13.10.11.34 NMAC apply to approved health plans for individual coverage. B. Members may utilize their normal business practices…

This rule applies to all persons who transact the business of health insurance in New Mexico or have dealings with the alliance.

A. An employer is eligible as a small employer if: (1) the employer, if a corporation, is incorporated in New Mexico or is authorized to do business in New Mexico; if a person or other organization, is a resident of this state or has its principal place of business in this state;…

A. Eligible employees. (1) An employee of a small employer (or a self-employed person who is eligible under Subparagraph (b) of Paragraph (3) of Subsection A of 13.10.11.20 NMAC) is eligible to enroll in an approved health plan if: (a) the employee (or the self-employed person) h…

The alliance shall require documentation that the employer qualifies as a small employer and satisfies eligibility and participation requirements. The alliance is particularly concerned that self-employed individuals are actively working for their business at least 20 hours per w…

The alliance requires: A. a completed application; B. the employer's federal EID and New Mexico gross receipts tax ID numbers; or, for a new business that has not yet obtained tax ID numbers, a current valid business license; C. a waiver of coverage, in the form specified by the …

A. For groups that file New Mexico department of labor employer's quarterly wage and contribution report (schedule A - SUTA), tseq level1 \h \r0 he employer's most recent SUTA. (1) The employer must identify on the SUTA form each employee who is not eligible for coverage and must…

In order to be eligible to enroll in an alliance plan offered by an HMO, an employee or spouse must live or work within the HMO's service area. The HMO may approve exceptions on an individual basis in accordance with the HMO's usual business practice.

The employer must establish a waiting period for new employees. The minimum waiting period is 30 days. The maximum waiting period is 180 days. The waiting period must be the same for all employees of a small employer. At the time a small employer first obtains coverage through th…

Applications must be received by the alliance office within the time period for enrollment specified above. A. Timely enrollment. Employees and their dependents shall be entitled to enroll in an alliance plan during the following timely enrollment periods. (1) New employees and t…

A. If the documentation required by the alliance is received by the 15th of the month, coverage shall be reviewed for an effective date as of the first day of the following month. If the documentation required by the alliance is received after the 15th of the month, coverage shal…

A. Family coverage must be offered for: (1) the employee's lawful spouse; (2) the employee's natural-born or legally adopted unmarried child; (3) the employee's stepchild who is living in the employee's home and is chiefly dependent on the employee for support; and (4) a child wh…

Sections 59A-56-5 and 59A-56-21 NMSA 1978.

A. Definitions. As used in this section: (1) pre-existing condition means a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for coverage for the benefits whether or not any medical advice, …

A. In addition to continuation coverage under the act, other forms of continuation coverage may be available under federal law or other provisions of state law.Details of these other programs may be obtained from an employer, an agent, or the insurance division. With respect to c…

Services provided outside of the United States will be covered only if they are for emergency treatment.

A group must select one carrier (member) for all participants as of the effective date of the group coverage. A group may only change carriers and plan design, (e.g., level of deductible or co-pay/co-insurance), at the group's anniversary date. All changes must be received by the…

A. Eligibility as an individual. (1) An individual is eligible for an alliance plan outside of a small employer if: (a) as of the date of application for coverage the individual is a resident of the state of New Mexico and has an aggregate of 18 or more months of creditable cover…

Members shall be responsible for issuing certificates of creditable coverage for groups and individuals. A member may transfer this responsibility to an individual group only by means of a written agreement signed by both parties. The member may charge a reasonable fee for such s…

Permanent.

June 1, 2001, unless a later date is cited at the end of a section.

The purpose of this rule is to implement the Health Insurance Alliance Act, Chapter 59A, Article 56 NMSA 1978.

In addition to the definitions in Section 59A-56-3 NMSA 1978, as used in this rule: A. act means the Health Insurance Alliance Act, Chapter 59A, Article 56 NMSA 1978; B. alliance means the New Mexico health insurance alliance; C. plan or plan of operation means this rule.

A. All persons listed in Section 59A-56-4 NMSA 1978 of the act shall organize and remain members of the alliance as a condition of their authority to transact insurance business in New Mexico. B. Such persons who were authorized to transact insurance business in New Mexico as of …

A. There shall be a board of directors, who shall be appointed or elected in accordance with the provisions of the act. (1) The elected directors shall be elected by the members of the alliance as hereinafter provided. (a) There shall be an annual membership meeting of all the al…

New Mexico State Corporation Commission [Public Regulation Commission], Department of Insurance, Post Office Box 1269, Santa Fe, NM 87504-1269.

A. Issuers shall accept the J512 form for claims for professional dental services. B. Issuers may not require a dentist to use any code other than the CDT-1 codes for the initial filing of claims for dental care services, unless the use of supplemental codes are defined and permi…

A. Issuers shall: (1) accept the most current editions of the HCFA form 1500, HCFA form 1450, or J512 form completed in accordance with the most current instructions for these forms from health care practitioners and institutional care practitioners; and (2) modify their claim re…

A. Except as otherwise specifically provided, the requirements of this rule apply to issuers as defined herein. B. Nothing in this rule shall prevent an issuer from requesting additional information that is not contained on the forms required under this rule to determine eligibil…

Sections 59A-2-9 and 59A-18-27.1 NMSA 1978.

Permanent.

July 1, 1994, unless a later date is cited at the end of a section or paragraph. Repromulgated in NMAC format effective July 1, 1997.

The purpose and intent of this rule is to implement the provisions of Section 59A-18-27.1 NMSA 1978, to standardize the forms used in the billing and reimbursement of health care expenses, to reduce the number of forms utilized, to increase efficiency in the reimbursement of heal…

A. "CDT - 1" codes means the current dental terminology prescribed by the American dental association. B. "CPT - 4" codes means the current procedural terminology published by the American medical association. C. "HCFA" means the health care financing administration of the U.S. d…