New Mexico Administrative Code

Permanent.

November 20, 1979, unless a later date is cited at the end of a section or paragraph. Repromulgated in NMAC format effective July 1, 1997.

The purpose of this rule is to specify the requirements for prepaid dental organizations in accordance with the Prepaid Dental Plan Law, Section 59A-48-1 NMSA 1978 et seq.

For the purpose of this rule: A. "Agent" means a person appointed by a prepaid dental plan to transact business in this state to act as its representative in any given locality for the purpose of soliciting members to be enrolled by contract providing dental care. B. "Director of…

For the protection of the public in New Mexico, the superintendent will issue, renew and permit to exist any prepaid dental plan to enroll members in a group to provide a prepaid dental plan in compliance with the provisions of Section 59A-48-1 NMSA 1978 et seq., with respect to …

A. Where this rule requires a prepaid dental plan to have policies, procedures, plans, class specification, orders, reports, minutes of meetings, contracts, agreements, records, duty schedules, or other such items, such requirement means written documents compiled and indexed in …

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

A. Independent accountant: Whenever the superintendent orders, or this rule requires, that a financial statement or other report be audited or be accompanied by the opinion of a certified public accountant or public accountant, the accountant shall be independent of the HMO. B. C…

If the reporting requirements of this rule duplicate any federal reporting requirements, the HMO may request a waiver of the reporting requirements of this rule. In requesting such a waiver, the HMO must clearly state which federally required information will be duplicated by com…

Each HMO shall have a fiscally sound operation as demonstrated by: A. total assets being greater than total unsubordinated liabilities by an amount at least equal to the net worth requirements delineated in Section 59A-46-13 NMSA 1978; B. sufficient cash flow and adequate liquidi…

Each HMO shall have administrative and managerial arrangements satisfactory to the superintendent as demonstrated by at least the following: A. a policy-making body which exercises oversight and control over the HMO's policies and personnel to assure that management actions are i…

Each HMO shall adopt at least one of the following arrangements to protect its enrollees from incurring liability for payment of any fees which are the legal obligation of the HMO: A. a contractual arrangement with any provider regularly used by the enrollees of the HMO prohibiti…

Each HMO shall assume full financial risk on a prospective basis for the provision of basic health services, except that it may: A. obtain insurance or make other arrangements for the cost of providing to any enrollee basic health services the aggregate value of which exceeds $5,…

With respect to any significant business transaction by the HMO with a party-in-interest: A. The HMO shall disclose to its policy-making body all material facts concerning the transaction and the party-in-interest's interest in the transaction. B. The policy-making body shall mak…

No later than one year after becoming operational as a certified HMO, an HMO shall either: A. assure that at least one-third of the membership of the HMO's policy-making body are enrollees of the HMO and that they reside in, or in proximity to, the service area of the HMO. No enr…

The superintendent may waive or modify any part of this rule in order to facilitate the purchase of HMO services by federal or state agencies in New Mexico.

This rule applies to all health maintenance organizations (HMOs).

Sections 59A-46-9, 59A-46-12, 59A-46-22 and 59A-46-23 NMSA 1978.

Permanent.

June 1, 1998, unless a later date is cited at the end of a section or paragraph.

The purpose of this rule is to ensure that HMO's meet minimum fiscal operational requirements sufficient to assume the risk of their covered subscribers and to establish requirements for the membership of HMO policy-making bodies.

In addition to the definitions in 59A-46-2 NMSA 1978, the following terms have the meanings given here. A. "Health professional" includes physicians, dentists, registered nurses, licensed practical nurses, podiatrists, optometrists, chiropractic physicians, physician assistants, …

An HMO shall be treated as a life insurance company for purposes of applying the provisions of Chapter 59A, Article 9 NMSA 1978.

In addition to the requirements of Section 59A-46-9 NMSA 1978, each HMO shall provide to the superintendent on or before March 1 of each year, unless for good cause shown the superintendent authorizes an extension of time, the following: A. a copy of the report, if any, filed wit…

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