New Mexico Administrative Code

A. Issuer's procedures. An issuer, directly or through its producers, shall: (1) establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate; (2) establish marketing procedures to assure excessive insurance i…

A. Agent's responsibility. In recommending the purchase or replacement of any Medicare Supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. B. Duplicate policies prohibited. Any sale of …

A. Appendix B due date. On or before March 1 of each year, an issuer shall report to the superintendent the following information for every individual resident of this state for which the issuer has in force more than one Medicare Supplement policy or certificate using the form r…

A. If a Medicare Supplement policy or certificate replaces another Medicare Supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare …

Section 59A-2-9, Subsection D of Section 59A-18-12, Subsection B of Section 59A-18-13, Paragraph (4) of Subsection A of Section 59A-23-3 and Section 59A-24A-1 et seq. NMSA 1978.

This Section applies to all policies with policy years beginning on or after May 21, 2009. A. Use of genetic testing - exclusion and discrimination. An issuer of a Medicare Supplement policy or certificate; (1) Shall not deny or condition the issuance or effectiveness of the poli…

If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby.

A. Appendix A - medicare supplement refund calculation form. For the required Medicare Supplement Refund Calculation Form for each calendar year, use the form so named and instructions provided in Appendix A of the Model Regulation To Implement the NAIC Medicare Supplement Insura…

Permanent.

The purpose of this regulation is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare Supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such poli…

January 1, 2019, unless a later date is cited at the end of a section.

For purposes of this regulation: A. "1990 Standardized Medicare Supplement benefit plan," "1990 standardized benefit plan" or "1990 Plan" means a group or individual policy of Medicare Supplement insurance issued on or after July 1, 1992 with an effective date prior to June 1, 20…

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare Supplement policy or certificate unless the policy or certificate contains definitions or terms that conform to the requirements of this section. A. "Accident," "accidental in…

A. Except for permitted preexisting condition clauses as described in Paragraph (1) of Subsection A of 13.10.25.10 NMAC, Paragraph (1) of Subsection A of 13.10.25.11 NMAC, and Paragraph (1) of Subsection A of 13.10.25.13 NMAC, no policy or certificate may be advertised, solicited…

New Mexico Public Regulation Commission, Insurance Division.

This rule applies to private health insurance cooperatives established under Chapter 59A, Article 23 NMSA 1978.

Sections 59A-2-9 and 59A-23-3 NMSA 1978.

Permanent.

October 15, 2012, unless a later date is cited at the end of a section.

To establish minimum registration requirements for private health insurance cooperatives.

A. "Private health insurance cooperative" means a nonprofit corporation formed to arrange for health benefit plan coverage with insurance carriers for its participating member large or small employers. B. "Carrier" means carrier as defined in Section 59A-23-11.Q (1) NMSA 1978. C.…

A. Any private health insurance cooperative operating in New Mexico shall register with the agent licensing bureau of the insurance division of the New Mexico public regulation commission prior to commencing operations. B. All business entities should be aware that other licensin…

A. Each private health insurance cooperative shall file an annual report for the preceding calendar year with the superintendent on or before March 1 of each year, or within such extension of time as the superintendent for good cause may grant. The report shall be in the form and…

New Mexico Office of Superintendent of Insurance.

Sections 59A-2-9, 59A-22-50, 59A-23C-10, 59A-46-51 and 59A-47-46 NMSA 1978.

As used in this rule: A. "health insurer" means a person duly authorized to transact the business of health insurance in the state pursuant to the Insurance Code but does not include a person that only issues an excepted benefit policy intended to supplement major medical coverag…

A. General requirement. Carriers shall meet the minimum medical loss ratio established, and in the manner calculated, under this rule. B. Measurement period. Compliance with the minimum medical loss ratio shall be measured over a rolling three-year period. The initial measurement…

A. An Insurer shall use an OSI approved form to submit minimum loss ratios. B. The form shall be posted to the OSI website.

Office of Superintendent of Insurance (OSI), Life and Health (L&H)

The provisions of this section apply equally to initial credentialing applications and applications for re-credentialing. A. Credential verification program. (1) In order to ensure accessibility and availability of services, each health carrier shall establish a program in accord…

A. Initiation of credentialing process. The credentialing process may be initiated by a provider, who either: (1) provides a completed uniform credentialing form directly to the health carrier; or (2) notifies the health carrier that the provider is requesting credentialing by th…

A. Terms for reimbursement. A health carrier shall reimburse a provider, subject to co-payments, co-insurance, deductibles, or other cost-sharing provisions, for any clean claims for covered services, provided that: (1) the date of service is more than 45 calendar days after the …

A. Internal review process. (1) Each health carrier shall establish an internal process for resolving disputes regarding payment of claims between the health carrier and providers arising when a credentialing decision is delayed beyond the timeline found in Subsection C of 13.10.…

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 carriers, including health maintenance organizations, individual health plans, group and blanket plans, provider service networks, non-profit healthcare plans and third-party payers or their agents that provide, offer or administe…

Sections 59A-16-20; 59A-16-21.1, 59A-22-54, 59A-23-14, 59A-46-54, and 59A-47-48 NMSA 1978.

Permanent.

January 1, 2017, unless a later date is cited at the end of a section.

The purpose of this rule is to establish a uniform and efficient provider credentialing process and to ensure that providers receive prompt payment from health carriers for clean claims and interest on unpaid claims. This rule also establishes a process for resolving payment-rela…

As used in this rule: A. "Business day" means a consecutive 24-hour period, excluding weekends or holidays. B. "Claim" means a request from a provider for payment for health care services. C. "Clean claim" means a manually or electronically submitted claim from an eligible provid…

A. General. (1) Health carriers shall comply with both the provisions of this section and with the provisions of 13.10.12 NMAC, which provides for standardization of health claim forms. (2) Claims information, including claim status information shall be subject to state and feder…

A. Payment of claims - timeliness. (1) Claim payment. Health carriers shall promptly pay providers upon receipt of clean claims for uncontested covered health care services that the provider has supplied. (2) Timeliness. The health carrier shall reimburse the eligible provider wi…

Office of Superintendent of Insurance ("OSI").

This rule requires screening of all uninsured patients receiving health care services in covered facilities to determine eligibility for health insurance programs, and to determine indigency for the purpose of prohibiting medical debt collection for indigent patients.

Sections 59A-2-9 NMSA 1978 and New Mexico Senate Bill 71 from the 2021 Regular Session the Patients' Debt Collection Protections Act NMSA Chapter 57.

Emergency rule expires 180 days from effective date unless a permanent rule is adopted before that time.

July 1, 2021 unless a later date is cited at the end of a section.

To ensure that health care facilities and covered third-party health care providers screen and identify patients who are indigent, eligible for Medicaid or other health insurance, and ensure that medical debt incurred by indigent patients will not be pursued through collection ac…

For definitions of terms contained in this rule, refer the Patients' Debt Collection Protection Act or in Chapter 59A NMSA 1978, unless otherwise noted below. A. "Culturally and linguistically appropriate" means communication that meets the following requirements:(1) the provisio…

A health care facility shall screen and offer to assist patients in obtaining Medicaid, public and other insurance, accessing public programs that assist with health care costs other financial assistance offered by the facility, before seeking payment for emergency or medically n…