New Mexico Administrative Code

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, and to regulate trade practices in the insurance business and related businesses by prohibiting unfair or…

In addition to the following, this rule is subject to the definitions found in the Grievance Procedures Rule, 13.10.17 NMAC. A. "Claim" means: (1) any request by an insured for indemnification by a MHCP; and (2) any direct services provided to an individual. B. "Direct services" …

A. Provider network adequacy: Each health care insurer through its MHCP shall maintain and have available an adequate network of licensed primary care practitioners (PCPs) to provide comprehensive basic health care services to its enrolled population at all times. Those MHCPs cur…

A. Utilization management program: The health care insurer through its MHCP shall establish and implement a comprehensive utilization management program to monitor access to and appropriate utilization of health care services. The program shall be under the direction of a medical…

Public Regulation Commission, Insurance Division.

A. Transfer of medical records. Each health care insurer shall develop and implement a policy for the transfer of medical records of a covered person whenever the following occur: (1) change of physician or other health care professional; (2) disenrollment of enrollee from the ma…

A. Guaranteed renewability: (1) In addition to the guaranteed renewability provisions pertaining to individuals, pursuant to NMSA 1978, Section 59A-23E-19, and under group health plans, pursuant to NMSA 1978, Section 59A-23E-14, health care insurers through managed health care pl…

A. A health care insurer or managed health care plan shall not use a deceptive name. B. A name will be considered deceptive if it unreasonably suggests: (1) the quality of care provided by the health care insurer or managed health care plan; (2) that full benefits are provided fo…

A. Deceptive advertising prohibited. No health care insurer may cause or knowingly permit the use of advertising or solicitation that is untrue or misleading, or may cause or knowingly permit any form of summary of benefits or evidence of coverage which is deceptive. B. Approval …

Each health care insurer shall offer continuation and transition of treatment to covered persons in compliance with the Insurance Code and applicable rules. A. If a covered person's health care provider leaves the MHCP's network of providers, the MHCP shall permit the covered per…

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 all health care insurers that provide, offer, or administer managed health care plans subject to the Insurance Code of the state of New Mexico: B. Exemptions. This rule does not apply to policies or certificates that provide coverage for: (1…

Sections 59A-1-18, 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5, 59A-59A-15 -16, 59A-16-4, 59A-16-5, 59A-16-11, 59A-16-12, 59A-16-12.1, 59A-16-13, 59A-16-15, 59A-16-16, 59A-16-17, 59A-18-16, 59A-19-4, 59A-19-5, 59A-19-6, 59A-23E-15, 59A-44-34, 59A-44-41, 59A-46-7, 59A-46-8, 59A-46-23, 59A-…

Permanent.

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

The purpose of this rule is to clarify contracting between both the health care insurer and enrollees and health care providers under managed health care plans.

A. In addition to the following, this rule is subject to the definitions found in Managed Health Care - Benefits, 13.10.13 NMAC. B. "Medical record" means all information maintained by a health care provider relating to the past, present or future physical or mental health of a p…

A. Evidence of coverage: At the time of enrollment, each managed health care plan (MHCP) shall provide each covered person with information on how to access and obtain an evidence of coverage. Upon request at any time after enrollment, the covered person shall be provided with th…

A. A MHCP shall not cancel the coverage of an enrollee except for "good cause," which, for the purposes of this section means: (1) failure of the enrollee or subscriber to pay the premiums and other applicable charges for coverage; (2) material failure to abide by the rules, and/…

New Mexico Public Regulation Commission Insurance Division.

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 …

This rule applies to all insurers issuing or delivering in the state of New Mexico medicare supplement policies, certificates or contracts with policy years beginning on or after May 21, 2009.

Sections 59A-2-9 and 59A-24A-1 et seq. NMSA 1978.

Permanent.

May 26, 2009, unless a later date is cited at the end of a section.

The purpose of this rule is to provide for nondiscrimination based on genetic information in the issuance and pricing of medicare supplement policies or certificates of coverage, and to generally prohibit insurers' requests for genetic testing except for limited use in determinin…

As used in this rule: A. "certificate" means any certificate delivered or issued for delivery in this state under a group medicare supplement policy; B. "family member" means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, …

A. An issuer of a medicare supplement policy or certificate: (1) shall not deny or condition the issuance or effectiveness of the policy or certificate (including the imposition of any exclusion of benefits under the policy based on a pre-existing condition) on the basis of the g…

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…

Office of Superintendent of Insurance.

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare Supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions …

A. General Standards. The following standards apply to 1990 Benefit Standardized Plan policies and certificates and are in addition to all other requirements of this regulation. (1) Preexisting conditions. Refer to Paragraph (1) of Subsection A of 13.10.25.10 NMAC. (2) Loss from …

A. An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic core benefits, as defined in Subsection E of 13.10.25.11 NMAC. B. No groups, packages or combinations of Medicare Supplement benef…

The following standards are applicable to all Medicare Supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for …

The following standards are applicable to all Medicare Supplement policies or certificates delivered or issued for delivery in this state on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare …

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the following standards are applicable to all Medicare Supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for Medicare on or after January 1, 20…

A. Applicability. (1) This section shall apply to Medicare Select policies and certificates, as defined in this section. (2) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. B. Authorization. T…

A. Plan availability. An issuer shall not deny or condition the issuance or effectiveness of any Medicare Supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience,…

A. Guaranteed issue. (1) Eligibility. Eligible persons, as defined in the Balanced Budget Act of 1997, are those individuals described in Subsection B of this section who seek to enroll under the policy during the period specified in Subsection C of this section, and who submit e…

A. An issuer shall comply with section 1882(c)(3) of the Social Security Act (42 U.S.C. § 1395ss(c)(3), as enacted by section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203) by: (1) accepting a notice from a Medicare carrier on dua…

A. Except as otherwise specifically provided in Sections 10, 19, 20, 23 and 28 of 13.10.25 NMAC this regulation shall apply to: (1) All Medicare Supplement policies delivered or issued for delivery in this state before or after the effective date of this regulation; and (2) All c…

A. Loss ratio standards. (1) Return of premiums. (a) A Medicare Supplement policy form or certificate form shall not be delivered unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, i.e.,…

A. Filing policies and certificates. An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed and approved electronically in SERFF or as otherwise designated by the superintende…

A. First year. An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare Supplement policy or certificate only if the first year commission or other first year compensation is no more than two-hundred per…

A. General rules. (1) Renewal or continuation. Medicare Supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. The provision shall be appropriate…

A. Statements and questions. Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare Supplement, Medicare Advantage, Medicaid coverage, or another health insuranc…

An issuer shall provide a copy of any Medicare Supplement advertisement intended for use in this state whether through written, radio or television medium to the superintendent for review and approval electronically in SERFF or as otherwise designated by the superintendent, pursu…