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
section.
A.
Proof of coverage
required. Carriers must obtain proof of major medical coverage prior to
the issuance of a plan subject to this section. Proof shall be demonstrated
through:
(1)
Individual plans:
(a) A copy of the current insurance card;
or
(b) the insurer name, group, and
policy number.
(2)
Employer-group, labor unions and group plans issued through a bona fide
association:
(a) A copy of the current
insurance card of each subject employee or group member;
(b) the insurer name, group, and policy
number of each subject employee or group member; or
(c) the insurer name(s) and the group
number(s) of the major medical plan(s) purchased by the group.
B.
Disclosure
required.
(1)
Initial
disclosure. Plans issued in accordance with this section must include
the following prominently displayed disclosure statement on the application,
and enrollment form, as well as on the policy or certificate of coverage issued
to each covered person.
COMPANY NAME
[SPECIFIC EXCEPTED BENEFIT PLAN TYPE] INSURANCE
REQUIRED DISCLOSURE STATEMENT
This [policy] [certificate of coverage] provides [Specific
Excepted Benefit Plan Type] ONLY. This [policy] [certificate of coverage] does
NOT provide major medical insurance, as defined under New Mexico Law.
[Accurately list benefits, exclusions, reductions and
limitations of the policy in a manner that does not encourage misrepresentation
of the actual coverage provided.] OR provide a copy of the approved outline of
coverage containing this information]
This disclosure statement is a very brief summary of your
[policy] [certificate of coverage]. The [policy] [certificate of coverage]
itself sets forth the rights and obligations of both you and the insurance
company. It is therefore imperative that you READ YOUR [POLICY][CERTIFICATE OF
COVERAGE] carefully.
The expected loss ratio for this policy is [ ]%. This ratio
is the portion of future premiums that the company expects to pay as benefits
under this policy, when averaged over all individuals with this policy or
certificate of coverage.
(2)
Annual disclosure. Upon renewal, or if coverage is not renewed
yearly then not less than annually, the insurer must provide each insured and
policyholder the statement listed below. For insurance issued on a group basis,
the statement may be provided to the policyholder for distribution to each
person insured under the policy.
NOTICE TO BUYER: PLEASE REVIEW THIS PLAN CAREFULLY. IT ONLY
PROVIDES LIMITED BENEFITS, AND IT DOES NOT ON ITS OWN OR IN COMBINATION WITH
OTHER LIMITED BENEFITS POLICIES CONSTITUTE MAJOR MEDICAL INSURANCE. BENEFITS
PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL
EXPENSES.
TO LEARN IF YOU ARE ELIGIBLE FOR A MAJOR MEDICAL PLAN,
PREMIUM DISCOUNTS, OR FINANCIAL ASSISTANCE, PLEASE VISIT [WWW.BEWELLNM.COM] OR CALL
[1-833-862-3935].
C.
Ancillary plans. Plans issued
in accordance with this section shall be considered ancillary to the underlying
major medical or comprehensive health plan.
(1)
Exemptions. Ancillary plans
shall not be required to comply with the following provisions of the rule:
(a) 13.10.34 10- ADDITIONAL REQUIREMENTS FOR
ACCIDENT ONLY PLANS
(b)
13.10.34.11- ADDITIONAL REQUIREMENTS FOR HOSPITAL INDEMNITY PLANS
(c) 13.10.34.12- OTHER FIXED INDEMNITY
BENEFITS
(d) 13.10.34.13-
ADDITIONAL REQUIREMENTS FOR SPECIFIED DISEASE PLANS
(e) 13.10.34.14-ADDITIONAL REQUIREMENTS FOR
HOSPICE CARE BENEFITS
(f)
13.10.34.18- REQUIRED DISCLOSURE AND NOTICES
(2)
Requirements. Ancillary
plans offered in accordance with this section are subject to these additional
requirements:
(a)
Treatment
trigger. Benefits offered pursuant to this section may be conditioned
upon a covered person receiving medical care given in a medically appropriate
location. A carrier shall not condition payment for any such benefit on prior
approval of treatment or on medical necessity.
(b)
Basis of compensation. Plans
offered pursuant to this section shall provide benefits only on a fixed
indemnity basis.
(c)
Benefit
maximum. Other fixed indemnity benefits shall be limited to
hospitalization, outpatient services, ambulance and other transportation
services, behavioral health services, laboratory and imaging services, in-home
care, durable medical equipment, home, work or vehicle modifications to
accommodate disability, therapy services, treatment-related lost wages, health
care related lodging, pet care and daycare services, or cosmetic services
relating to a covered accident or illness. Other fixed indemnity benefits
offered pursuant to this section shall not be in excess of $500,000.
D.
MEWAs.
MEWAs and non-employer groups subject to the provisions of
13.19.4 NMAC may not
offer ancillary plans in accordance with this section, unless the coverage is
offered through a bona fide association.
Notes
N.M. Admin.
Code §
13.10.34.23
Adopted by
New
Mexico Register, Volume XXXV, Issue 01, January 16, 2024, eff.
1/1/2025
