New Mexico Administrative Code

A. Issuers shall accept from health care practitioners other than dentists the HCFA form 1500 for claims for professional services. B. Issuers may not require health care practitioners to use any coding system for the initial filing of claims for health care services other than t…

A. Issuers shall accept from institutional care practitioners the HCFA form 1450 for claims for health care services. B. Issuers may not require institutional care practitioners to use any coding system for the initial filing of claims for health care services other than the foll…

New Mexico Public Regulation Commission, Division of Insurance, Post Office Box 1269, Santa Fe, New Mexico 87504-1269.

A. No MHCP that provides coverage for prescription drugs as a basic or supplemental health care service or pursuant to inpatient, urgent, or emergency medical services shall limit or exclude coverage for any drug approved by the FDA on the basis that the drug has not been approve…

A. A health care insurer may or may not coordinate benefits in some or all of its group and individual managed health care plan contracts. However, a health care insurer which does coordinate benefits may do so only pursuant to the provisions in its plan contracts, all of which s…

A. All cost sharing (including copayments, deductibles, co-insurance, or similar charges) required of covered persons by the health care insurer or managed health care plan for the provision of health care services shall be reasonable and shall include any applicable state and fe…

A. Consumer assistance office: Each MHCP shall establish and adequately staff a consumer assistance office. Those MHCPs currently doing business in New Mexico shall submit to the superintendent for approval a plan of how the MHCP's consumer assistance office will be organized and…

In addition to any applicable suspension, revocation or refusal to continue any certificate of authority or license under the Insurance Code, a penalty for any material violation of this rule may be imposed against a health care insurer by the superintendent in accordance with Se…

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 …

A. Applicability. This rule applies to health care insurers that are required to obtain a certificate of authority or licensure in this state and which provide, offer, or administer managed health care plans. B. Exemptions. This rule does not apply to policies or certificates tha…

Sections 59A-1-18, 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5, 59A-15-16, 59A-18-21, 59A-19-5, 59A-19-6, 59A-22-19, 59A-22-20, 59A-22-21, 59A-22-42, 59A-22-43, 59A-22A-4, 59A-22A-5, 59A-22A-6, 59A-22A-7, 59A-23E-15, 59A-44-41, 59A-46-23, 59A-46-25, 59A-46-30, 59A-47-24, 59A-47-25, 59A-47…

Permanent.

September 1, 2009, unless a later date is cited at the end of a section.

The purpose of this rule is to ensure the availability, accessibility, and quality of health care services provided by health care insurers through managed health care plans. The rule provides uniform definitions; standards regarding patient rights and responsibilities; requireme…

In addition to the following, this rule is subject to the definitions found in the Grievance Procedures Rule, 13.10.17 NMAC. A. "Certified nurse-midwife" means any person who is licensed by the board of nursing as a registered nurse and who is licensed by the New Mexico departmen…

A. Each health care insurer through its managed health care plan (MHCP) shall implement written policies and procedures regarding the rights of covered persons and implementation of such rights. B. At the time of enrollment, each health care insurer through its MHCP shall provide…

A. A health care insurer, through its MHCP, may provide to its covered persons supplemental health care services that are not basic health care services. For HMOs, basic health care services are defined and described at 13.10.21.8 NMAC. These supplemental health care services may…

New Mexico Public Regulation Commission, Insurance Division.

A. Interest. The maximum interest rate for claim reserves is specified in 13.10.14.24 NMAC. B. Morbidity. Minimum standards with respect to morbidity are those specified in 13.10.14.22 and 13.10.14.23 NMAC, except that, at the option of the insurer: (1) For claims with a duration…

A. Interest. The maximum interest rate for claim reserves is specified in 13.10.14.24 NMAC. B. Morbidity or other contingency. The reserve should be based on the insurer's experience, if such experience is considered credible, or upon other assumptions designed to place a sound v…

A generally accepted actuarial reserving method or other reasonable method, if, after a public hearing, the method is approved by the superintendent prior to the statement date, or a combination of methods may be used to estimate all claim liabilities. The methods used for estima…

A. Unearned premium reserves are required for all contracts with respect to the period of coverage for which premiums, other than premiums paid in advance, have been paid beyond the date of valuation. B. If premiums due and unpaid are carried as an asset, such premiums must be tr…

A. The minimum unearned premium reserve with respect to any contract is the pro rata unearned modal premium that applies to the premium period beyond the valuation date, with such premium determined on the basis of: (1) the valuation net modal premium on the contract reserve basi…

The insurer may employ suitable approximations and estimates; including, but not limited to groupings, averages and aggregate estimation; in computing premium reserves. Such approximations or estimates should be tested periodically to determine their continuing adequacy and relia…

The contract reserve is in addition to claim reserves and premium reserves. A. Contract reserves required. Contract reserves are required, unless otherwise specified in Subsection B of 13.10.14.16 NMAC, for: (1) all individual and group contracts with which level premiums are use…

A. Morbidity or other Contingency. Minimum standards with respect to morbidity are those set forth in 13.10.14.22 and 13.10.14.23 NMAC. Valuation net premiums used under each contract must have a structure consistent with the gross premium structure at issue of the contract as th…

Provided the contract reserve on all contracts to which an alternative method or basis is applied is not less in the aggregate than the amount determined according to the applicable standards specified above; an insurer may use any reasonable assumptions as to interest rates, ter…

Annually, an appropriate review shall be made of the insurer's prospective contract liabilities on contracts valued by tabular reserves, to determine the continuing adequacy and reasonableness of the tabular reserves giving consideration to future gross premiums. The insurer shal…

This rule applies to all individual and group health insurance coverages except credit insurance.

In the event a company has a contract or a group of related similar contracts, for which future gross premiums will be restricted by contract, insurance department regulations, or for other reasons, such that the future gross premiums reduced by expenses for administration, commi…

Increases to, or credits against reserves carried, arising because of reinsurance assumed or reinsurance ceded, must be determined in a manner consistent with these minimum reserve standards and with all applicable provisions of the reinsurance contracts which affect the insurer'…

A. Disability Income Benefits Due to Accident or Sickness. (1) Contract Reserves. (a) For contracts issued on or after January 1, 1997, the 1985 commissioners individual disability tables A (85CIDA); or The 1985 commissioners individual disability tables B (85CIDB). Each insurer …

A. Disability Income Benefits Due to Accident or Sickness. (1) Contract reserves. Contracts issued on or after January 1, 1997, the 1987 commissioners group disability income table (87CGDT). (2) Claim reserves. (a) For claims incurred on or after January 1, 1997, the 1987 commiss…

A. For contract reserves the maximum interest rate is the maximum rate permitted by law in the valuation of whole life insurance issued on the same date as the health insurance contract. B. For claim reserves on policies that require contract reserves, the maximum interest rate i…

A. Unless Subsection B of 13.10.14.25 NMAC applies, the mortality basis used for all policies except long-term care individual policies and group certificates and for long-term care individual policies and group certificates issued before January 1, 1997 shall be according to a t…

Duration Adjustment Factor Adjusted Termination Factor* Week 1 0.366 0.04831 2 0.366 0.04172 3 0.366 0.04063 4 0.366 0.04355 5 0.365 0.04088 6 0.365 0.04271 7 0.365 0.04380 8 0.365 0.04344 9 0.370 0.04292 10 0.370 0.04107 11 0.370 0.03848 12 0.370 0.03478 13 0.370 0.03034 Month 4…

Sections 59A-2-8, 59A-2-9, 59A-8-4, 59A-8-6, 59A-8-7, and 59A-8-8 NMSA 1978.

Permanent.

October 1, 2003, unless a later date is cited at the end of a section.

The objective of this rule is to promote solvency by establishing minimum standards for the computation of reserves, which place a sound value on liabilities issued under both individual and group health insurance contracts.

As used in this valuation standard, the following terms have the meanings given here. A. "Annual claim cost." The net annual cost per unit of benefit before the addition of expenses, including claim settlement expenses, and a margin for profit or contingencies. For example, the a…

A. When an insurer determines that adequacy of its health insurance reserves requires reserves in excess of the minimum standards specified herein, such increased reserves shall be held and shall be considered the minimum reserves for that insurer. B. With respect to any block of…

A. Claim reserves are required for all incurred but unpaid claims on all health insurance policies. B. Appropriate claim expense reserves are required with respect to the estimated expense of settlement of all incurred but unpaid claims. C. All such reserves for prior valuation y…

New Mexico Public Regulation Commission, Insurance Division.

A. No policy may be delivered or issued for delivery in this state as long-term care insurance if such policy limits or excludes coverage by type of illness, treatment, medical condition or accident, except as follows: (1) preexisting conditions or diseases; (2) mental or nervous…

Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the long-term care insurance was in force and continues without interruption after termination. Such extension of benefits …

A. Group long-term care insurance issued in this state on or after July 1, 1997 shall provide covered individuals with a basis for continuation or conversion of coverage. B. Continuation of coverage or issuance of a converted policy shall be mandatory, except where: (1) terminati…

A. Group policies which restrict provision of benefits and services to, or contain incentives to use, certain providers and/or facilities may provide continuation benefits which are substantially equivalent to the benefits of the existing group policy. The Superintendent shall ma…

A. Where the group policy from which conversion is made restricts provision of benefits and services to, or contains incentives to use, certain providers and/or facilities, the Superintendent, in making a determination as to the substantial equivalency of benefits, shall take int…

If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to indi…