New Mexico Administrative Code

The purpose of this rule is to establish regulatory requirements for the subject excepted benefit plans. The rule will standardize and simplify the terms and coverages; facilitate public understanding and comparison of coverage; eliminate provisions that may be misleading or conf…

For definitions of terms contained in this rule, refer to 13.10.29 NMAC, unless otherwise noted below. A. "Accident only plan" means an insurance agreement that conditions a fixed indemnity benefit on the occurrence of an injurious accident. B. "Certificate" means a document that…

A plan subject to this rule shall comply with these provisions: A. Probationary periods A plan shall not include a probationary or waiting period during which no coverage is provided for a covered benefit after the coverage effective date. A probationary period does not include a…

A disability income plan is subject to these additional requirements: A. Benefit reduction A disability income plan may provide that benefits shall decrease by up to fifty percent if the covered person is or attains the age of 62 during the period of disability. B. Disability lim…

Office of Superintendent of Insurance ("OSI").

A. Applicability. This section applies only to subject dental plans. B. Definitions. For purposes of this Section:(1) "Dental plan" is a policy, contract, agreement or arrangement under which an entity undertakes to reimburse claims for the cost of dental services and dental supp…

A. Applicability. This section only applies to subject vision plans. B. Definitions. For purposes of this section:(1) "covered materials" means materials that are reimbursable by a vision plan to a vision care provider subject to any deductible, copayment, coinsurance, or other p…

A. A dental or vision plan shall only coordinate or combine benefits as permitted under state or federal law and as specified in the plan. B. A carrier and plan that offers both dental and vision benefits is subject to both the dental and vision provisions of this rule.

A. Coverage forms and benefits disclosures. (1) A carrier shall issue a policy, certificate of coverage or summary of benefits to each covered person on or before the effective date of coverage or of a change in coverage. Covered groups may distribute a certificate of coverage or…

Each dental or vision plan that in any way conditions coverage on the provision of services by a preferred provider shall maintain an adequate network of such providers: A. Attestation. A carrier shall submit to the superintendent annually an attestation of compliance with all of…

A. Denial of services. A benefit denial that is based on a determination that a dental or vision service is not medically necessary, and that is the result of a formal prior authorization review process, shall be supported by a contemporaneous opinion of a provider licensed to pr…

A carrier shall state in all plan documents that a covered person who cannot resolve a complaint with the plan may contact the office of the superintendent of insurance.

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 insurance carrier by the superintendent in accordan…

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 every carrier who offers or sells any individual or group dental or vision insurance plan ("plan") separately from a health benefits plan, whether on or off the exchange. This rule does not apply to any pediatric dental or vision plan, or to any prepaid denta…

Sections 59A-2-9, 59A-23F-7, and 59A-23G-1 et seq. NMSA 1978.

Permanent.

January 1, 2022 unless a later date is cited at the end of a section. If the superintendent previously approved a subject plan, that plan shall comply with this rule no later than January 1, 2022, if issued on or after that date.

Establish minimum regulatory standards and sales practices relating to dental and vision plans; standardize and simplify the terms and coverages; facilitate public understanding and comparison of coverage; eliminate provisions that may be misleading or confusing in connection wit…

For definitions of terms contained in this rule, refer to 13.10.29 NMAC, unless otherwise noted below. A. "Domestic co-insured" means a spouse or domestic partner insured under the same plan or certificate. B. "Earned premiums" for a reporting year means the premium received up t…

A. Probationary and waiting periods. Except as otherwise expressly allowed under Sections 10 and 11 of this rule, a plan shall not include any probationary or waiting period during which no coverage is provided for a covered benefit, except an eligibility waiting period during wh…

A. For individual plans. The following general standards apply to individual plans. (1) An individual plan shall have a minimum term of 12 months. (2) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" individual plan shall not provide for te…

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

This rule governs the agency's efforts to ensure a smooth transition into a QHP offered on the New Mexico health insurance exchange for individuals who no longer qualify for medicaid after the expiration continuous coverage requirement in the federal "families first coronavirus r…

This rule governs the agency's small business health insurance premium relief initiative, which applies to QHPs sold through the small business health options program or purchased directly from a health insurance issuer selling QHPs in the small group health insurance market. A. …

These rules govern the establishment and provision of a Health Care Affordability Plan and administration of the Health Care Affordability Fund (the "Fund").

Section 59A-23F-12 NMSA 1978 (the "Health Care Affordability Plan").

Permanent.

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

These rules establish policies, procedures, and controls for the establishment and maintenance of a "Health Care Affordability Plan" as funded by the "Health Care Affordability Fund" to achieve the public policy purposes in the manner prescribed under Sections 59A-23F-11 and 59A-…

Terms are as defined in the Insurance Code, and as supplemented below. A. "Advance state payments" means marketplace affordability program payments by the fund to a participating health insurance issuer on a monthly basis to lower premium and state out-of-pocket assistance for co…

This rule governs appropriation requests. A. Annually, the superintendent will submit appropriation requests to the legislative finance committee for each fund program. OSI will post proposed program parameters associated with the budget request on the agency's website upon submi…

This rule governs the annual state out-of-pocket assistance and premium assistance programs. A. Affordability criteria: Annually, the superintendent shall publish a bulletin specifying affordability criteria for the ensuing plan year. Absent extenuating circumstances that mandate…

Office of Superintendent of Insurance ("OSI").

This rule applies to health care facilities, third-party health care providers, medical creditors, medical debt collectors and medical debt buyers subject to Sections 57-32-1 to 57-32-10 NMSA 1978.

Sections 59A-2-9 NMSA 1978 and sections 57-32-1 to 57-32-10 NMSA 1978.

Permanent.

December 28, 2021 unless a later date is cited at the end of a section.

To ensure that health care facilities offer and provide screenings to uninsured patients who may be eligible for Medicaid or other public health insurance, and to ensure that medical debt incurred by indigent patients will not be pursued through certain proscribed collection acti…

For definitions of terms contained in this rule, refer to the Patients' Debt Collection Protection Act Sections 57-32-1 to 57-32-10 NMSA 1978 and in Chapter 59A NMSA 1978, unless otherwise noted below. A. "Culturally and linguistically appropriate" means communication that meets …

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

Collection action based on charges for health care services and medical debt may not be pursued against an indigent patient. A determination whether a patient is an indigent patient shall be made before collection action is pursued against the patient. A. Prohibited activity. Med…

New Mexico State Corporation Commission [Public Regulation Commission], Department of Insurance, Post Office Box 1269, Santa Fe, NM 87504-1269.

A. The format and content of an advertisement of an accident or health insurance policy shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive. Whether an advertisement has a capacity or tendency to mislead or deceive shall b…

A. Deceptive words, phrases or illustrations prohibited: (1) No advertisement shall omit information or use words, phrases, statements, references or illustrations if the omission of this information or use of these words, phrases, statements, references or illustrations has the …

An advertisement which is an invitation to contract shall disclose the provisions relating to renewability, cancellability and termination and any modification of benefits, losses covered, or premiums because of age or for other reasons, in a manner which shall not minimize or re…

A. Testimonials and endorsements used in advertisements must be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduced. The insurer, in using a testimonial or endorsement, makes as its own all of the statements co…

A. An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to any insurer or policy shall not use irrelevant facts, and shall not be used unless it accurately reflects all of the relevant facts. Th…

A. When a choice of the amount of benefits is referred to, an advertisement which is an invitation to contract shall disclose that the amount of benefits provided depends upon the plan selected and that the premium will vary with the amount of the benefits selected. B. When an ad…

A. An advertisement shall not directly or indirectly make unfair or incomplete comparisons of policies or benefits or comparisons of non-comparable policies of other insurers, and shall not disparage competitors, their policies, services or business methods, and shall not dispara…