New Mexico Administrative Code

Collection actions based on charges for health care services and medical debt may not be pursued against an indigent patient. A. Medical creditors, medical debt buyers, and medical debt collectors shall include a notice with each bill sent to a patient, informing the patient that…

Office of Superintendent of Insurance.

A. Qualified health plan standard requirements. A short-term plan is subject to the same rate, form, and compliance filings as qualified health plans. B. Network access plan. An insurer who offers a short-term plan shall file a network access plan(s) in SERFF for review and appro…

In addition to any applicable suspension, revocation or refusal to continue any certificate of authority or license under the Insurance Code, the superintendent may impose a penalty for any violation of this rule in accordance with Sections 59A-1-18 and 59A-46-25 NMSA 1978.

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 person's or circumstances, shall not be…

This rule applies to every health insurer who offers or issues a short-term plan to a resident of New Mexico.

Section 59A-23G-1 et seq. NMSA 1978.

Permanent.

Establish regulatory requirements for short-term health benefit plans. The rule will standardize and simplify the terms and coverages, facilitate public understanding and comparison of coverage, and prohibit provisions that may be misleading or confusing in connection with such p…

October 1, 2020, unless a later date is cited at the end of a section.

A. The definitions in Section 59A-23G-2 NMSA 1978 apply to this rule. B. Unless inconsistent with a term defined in this rule, or the usage of a term in this rule, the definitions in 13.10.29 NMAC apply.

A. Duration and non-renewability. The term of a short-term plan shall not exceed three months and shall not be extendable or renewable. Continuation and conversion rights of short-term plan dependents extend only to the original termination date of the policy. B. When issuance pr…

A. Disclosure Required. A short-term plan shall not be offered or issued without providing the prospective insured applicant a disclosure in the form and with the content specified in this section. B. Disclosure format. The standard disclosure shall be displayed prominently in th…

Office of Superintendent of Insurance ("OSI").

A. Health plans subject to 13.10.16 NMAC: a pharmacy grievance relating to a PBM who is performing services for a health plan or carrier subject to rule 13.10.16 NMAC shall be governed by that rule. B. Health plans not subject to 13.10.16 NMAC: A pharmacy with a grievance relatin…

Claims for reimbursement by a pharmacy are subject to the clean claims laws.

A. Submission of appeal. A network pharmacy that disputes a MAC reimbursement amount may submit a MAC appeal, to the PBM within 21 business days after a network pharmacy receives notice of the reimbursement amount. A PSAO may submit a MAC appeal on behalf of a network pharmacy. B…

A. Submission requirements. A MAC appeal submission include: (1) fill date; (2) BIN number (six digits); (3) NCPDP (seven digits); (4) Rx number; (5) NDC 11 (11 digits); (6) drug name; (7) drug strength; (8) invoice price and net purchase price of drug (whole dollar with two deci…

A. Update timeframe. A PBM shall update its MAC list at least once every seven days. B. Searchable online database required. A PBM shall establish a searchable online database that will allow a network pharmacy to search MAC list prices for a particular drug for as long as the ph…

A. Searchable list of drugs. A PBM shall maintain a searchable database containing all MAC list pricing for the preceding five years, but no earlier than January 14, 2021. The database shall be searchable by these criteria: (1) NDC number; (2) drug name; (3) specific health plan;…

A PBM applying for license renewal shall submit an annual report to the superintendent's PBM program coordinator with the license renewal application. The annual report shall contain the items outlined in 13.10.30.8 NMAC. Failure to comply with these requirements shall result in …

A. Confidentiality. Any PBM data received by the superintendent in response to a specific request shall be deemed confidential, unless disclosure is required for a regulatory purpose, enforcement, rulemaking, to respond to a legislative request, or is otherwise required by law or…

PBMs shall submit the following information to determine compliance with New Mexico law according to the schedule provided by the superintendent: A. Grievance and MAC appeal data. The PBM shall file a log of grievance and MAC appeal data using a form specified by the superintende…

A PBM shall not: A. Retaliate. Retaliate against a pharmacy for invoking its rights under these rules or the Pharmacy Benefits Manager Regulation Act. Selecting a pharmacy that has filed a grievance for audit at a rate disproportionately higher than for other network pharmacies m…

This rule applies to every pharmacy benefits manager ("PBM") and health insurance carrier subject to the jurisdiction of the office of superintendent of insurance.

A. Examination. Pursuant to the examination powers conferred by the Insurance Code, the superintendent may examine a PBM for compliance with any applicable New Mexico law. B. Data calls. Pursuant to the oversite and supervision powers conferred by the Insurance Code, the superint…

Every PBM shall maintain at its principal administrative office for the duration of the written agreement referred to in Section 59A-12A-4 NMSA 1978 and five years thereafter adequate books and records of all contracts and transactions. The superintendent shall have access to suc…

Failure to comply with any provision of these rules is a violation of the Insurance Code.

Any person aggrieved by any action, threatened action, or failure to act by the superintendent shall have the same right to a hearing before the superintendent with respect thereto as provided for in general under Chapter 59A, Article 4 NMSA 1978 and the implementing rules.

Failure to comply with any provision of these rules is a violation of the Insurance Code and punishable pursuant to Subsection B of Section 59A-1-18 NMSA 1978.

Section 59A-2-9 NMSA 1978 and Subsection C of Section 59A-61-3 NMSA 1978.

Permanent.

March 1, 2022, unless a later date is cited at the end of a section.

This rule establishes operating standards, licensing, reporting and record retention requirements for PBMs to implement and promote the objectives and policies of the Pharmacy Benefits Manager Regulation Act, Chapter 59A, Article 61 NMSA 1978.

For purposes of this rule and the Pharmacy Benefits Manager Regulation Act: A. "Clean claim" has the definition found in Paragraph (1) of Subsection A of Section 59A-16-21.1 NMSA 1978. B. "Client" means any person with whom a PBM contracts to provide pharmacy benefits management …

A PBM shall not conduct any operation or provide any service in New Mexico unless it holds a valid PBM license issued by the superintendent. A. A PBM shall apply for a license by submitting a complete application package on a form, and pursuant to the directions, prescribed by th…

A. Registration required. A PSAO shall not provide any service in New Mexico unless it is registered with the register with the superintendent. B. A PSAO's registration application shall be submitted on a form provided by the superintendent and shall include: (1) full business na…

Office of Superintendent of Insurance ("OSI").

A. Prior authorization forms. (1) A carrier shall accept the uniform prior authorization request form(s) developed by the superintendent and found on the superintendent's website at www.osi.state.nm.us. (2) A carrier may ask the superintendent to approve a non-uniform prior autho…

A. No later than January 1, 2022, a carrier shall implement a process to auto-adjudicate electronically submitted prior authorization requests. (1) A carrier shall comply with all statutory timelines applicable to prior authorization review. A list of all statutory prior authoriz…

A. Applicability. This section of the rule shall only apply to fully-insured commercial coverages regulated by the superintendent. B. Review of covered benefits that require prior authorizations. Annually, beginning in 2023, a carrier shall review its prior authorization requirem…

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 violation of this rule may be imposed against an insurer in accordance with Sections 59A-1-18 and 59A-46-25 NMSA 1978.

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 …

These rules apply to every: A. health insurer as defined in Subsection H of Section 59A-22B-2 NMSA 1978; B. multiple employer welfare arrangement; and C. Medicaid managed care organization, that requires prior authorization as a condition to payment for a medical service, pharmac…

Section 59A-2-9.8 NMSA 1978, Section 59A-15-20 NMSA 1978; Sections 59A-22B-1 through 59A-22B-5 NMSA 1978; and Sections 59A-57-1 through 59A-57-11 NMSA 1978.

Permanent.

To establish and standardize oversight, reporting, transparency and confidentiality procedures for prior authorization processes.

January 1, 2022, unless a later date is cited at the end of a section.

Terms used in these rules are as defined in Section 59A-22B-2 NMSA 1978, and in 13.10.29 NMAC, except as supplemented and superseded below. A. "Benefit" means any medical service, medical service location, medical provider selection, pharmaceutical, or medical supply that is the …

A carrier shall comply with the standard prior authorization processes specified in these rules. A. Responsibility for requesting prior authorization. (1) A carrier shall accept a prior authorization request submitted by a provider or by a covered person. (2) If a covered person …