New Mexico Administrative Code

A. A carrier shall: (1) accept prior authorization requests submitted at any time prior to the delivery of service; (2) accept prior authorization requests telephonically and by facsimile; (3) offer at least one bi-directional electronic prior authorization portal; (4) allow a pr…

Office of Superintendent of Insurance ("OSI").

A. If a prescription is not required for the purchase of a contraceptive, an insurer shall not charge a member for a purchase at an in-network pharmacy, and shall provide a process for the member to obtain reimbursement for an out-of-network purchase. B. An insurer's website and …

A dispute between an insurer and a covered person concerning a request to grant coverage for a contraceptive supply or service shall be processed in accordance with Sections 59A-23-12.1, 59A-47-47.1, 59A-22B-5, 59A-22-42, or 59A-46-52 NMSA 1978, as applicable, or 13.10.17 NMAC.

A. Forms. An insurer shall provide each covered person with a contraceptive coverage summary that clearly explains the scope of contraceptive coverage and how to access this benefit at least annually. The coverage summary through written materials or links to an insurer's website…

An Insurer who is legally obligated to provide contraceptive supplies or services shall do so without discriminating against the covered person on the basis of race, color, national origin, sex, sexual orientation, gender expression or identity, marital status, age, citizenship, …

An insurer who issues a health benefit plan that qualifies as a health savings account ("HSA-qualifying plan") is subject to this rule. A deductible under an HSA-qualifying plan for over-the-the counter contraceptive supplies or services and voluntary male sterilization shall not…

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 …

A. Applicability. This rule applies to every insurer who issues an individual or group health insurance policy, health care plan or certificate of health insurance that provides a prescription drug benefit for a resident of this state. Herein, each such insurer is referred to as …

Sections 59A-22-42, 59A-23.7.14, 59A-46-44 and 59A-47-45.5 NMSA 1978.

Permanent.

To clarify contraceptive coverage requirements.

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

A. 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. B. "provider" means, in addition to the definition in Paragraph (13) of Subsection P of 13.10.29.7 NMAC, pharmacists authorized to prescribe hormo…

A. Oral contraceptives. An insurer satisfies its obligation to cover a sufficient number and assortment of oral contraceptives to reflect the variety of oral contraceptives approved by the federal food and drug administration only if its plan covers contraceptive pills of differi…

A. Access. If an insurer's plan limits coverage of contraceptive services and supplies to in-network providers, the Insurer shall establish and maintain a network for these services and supplies that meets the access and adequacy standards set forth in state and federal network a…

New Mexico Office of Superintendent of Insurance ("OSI").

An out-of-network provider shall not bill a covered person for a potential surprise bill without first submitting the bill to the covered person's designated carrier and obtaining a payment or denial.

A carrier shall annually submit a surprise billing data report using a template provided by the superintendent. The template shall require a carrier to report changes to the percent of claims paid for emergency services. The report shall be filed annually by May 1st of each year …

A provider may dispute the denial, or reimbursement amount, of a surprise bill pursuant to the applicable procedures in 13.10.16 NMAC.

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 health insurance carrier ("carrier") that provides health coverage under a policy, arrangement, contract or plandescribed in Section 59A-57A-12 NMSA 1978.

Section 59A-2-9 NMSA 1978, Sections 59A-57A-1 through 59A-57A-13 NMSA 1978 and Section 59A-16-21.3 NMSA 1978.

Permanent.

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

To implement consumer protection, reimbursement, refund, reporting and appeal requirements for the surprise billing protection act.

For definitions of terms contained in this rule, refer to Section 59A-57A-2 NMSA 1978 and 13.10.29 NMAC.

A. Notice of payment and right to a refund. A carrier who reimburses a provider for a surprise bill shall provide the covered person an explanation of benefits ("EOB") showing, at a minimum, the name of the provider, the date of service, the amount billed and the amount paid. As …

A carrier shall afford a covered person these rights: A. Out of state care. A carrier shall reimburse a surprise medical bill as required by law regardless of the situs of delivery of the medical care, including medical care rendered out-of-state. B. Specific consent. For purpose…

New Mexico Office of Superintendent of Insurance ("OSI").

An accident-only plan is subject to these additional requirements. A. Plan definitions An accident-only plan:(1) shall not define "accident" more narrowly than an injurious event during the coverage period that was unexpected and unintended from the standpoint of the covered pers…

A hospital indemnity plan is subject to these additional requirements. A. Benefit minimum A hospital indemnity plan shall pay a minimum lump-sum of no less than $1,500 upon initial confinement. A plan may offer additional lump-sum or daily benefits for additional periods of confi…

Other fixed indemnity benefits are subject to these additional requirements. A. Benefits Other fixed indemnity benefits shall be no less than $50 per triggering event, circumstance or condition. The aggregate amount of all other fixed indemnity benefits offered shall not exceed $…

A specified disease plan is subject to these additional requirements. A. General requirements (1) A plan covering a single specified disease or combination of specified diseases shall not be sold or offered for sale other than as a specified disease plan. (2) A specified disease …

A hospital indemnity plan that provides hospice coverage, separately or in conjunction with other hospital indemnity coverage, is subject to these additional requirements. A. Scope The hospice benefit shall apply to care received in a facility or through an in-home program, licen…

A supplemental plan is subject to these additional requirements. A. Group coverage limitation A carrier shall only offer or issue a supplemental plan to a person who is covered under a primary group major medical, TRICARE or Champus plan. B. Plan design A supplemental plan must b…

A non-subject worker plan is subject to these additional requirements. A. Eligibility A non-subject worker plan shall only be offered or sold to a person who is self-employed and not subject to New Mexico workers' compensation law protections. A carrier shall investigate and eval…

A. Prior approval of forms required A carrier shall not issue, deliver or use a form associated with a plan, unless and until such form has been filed with and approved by the superintendent. B. Prior approval of rates required A carrier shall not use rates or modified rates for …

A. General notice requirement An application for an individual plan or plan sold through an association or group described in Paragraphs (2) or (4) of Subsection A of 59A-23-3 NMSA 1978, other than a disability income plan, shall contain in bold, 14-point type, directly above the…

A. Required questions. An application for an individual plan or a plan sold through an association or group described in Paragraphs (2) or (4) of Subsection A of 59A-23-3 NMSA 1978 shall ask whether the insurance requested will replace any other plan subject to this rule. B. Noti…

This section identifies the excepted benefits and excepted benefits products that are subject to this rule, and applicable exceptions. A. Subject products This rule applies to these excepted benefits products: (1) accident only; (2) specified disease or illness; (3) hospital inde…

A. Noncoordination of benefits Benefits under a plan shall: (1) be provided under a separate plan, certificate, or contract of insurance; (2) have no coordination with the benefits offered under a health plan; and (3) pay benefits regardless of any benefits provided under a healt…

The sale of any plan that does not comply with this rule is unlawful. In addition to any applicable suspension, revocation or refusal to continue any certificate of authority or license under the New Mexico Insurance Code, a penalty for any material violation of this rule may be …

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 …

Accident-only, specified disease or illness, hospital indemnity, and other fixed indemnity plans issued to individuals, employer groups, labor unions or group plans issued through bona fide associations, covered under a major medical plan shall comply with the provisions of this …

A. License required. All producers selling excepted benefits plans under this rule must maintain current licensure with the state in accordance with the New Mexico Insurance Code. B. Continuing education. Producers transacting in excepted benefits must complete at least two hours…

Sections 59A-18, 59A-16 and 59A-23G-3 NMSA 1978.

Permanent.

January 1, 2024, unless a later date is cited at the end of a section.