N.M. Admin. Code § 13.10.9.9 - POLICY OR PLAN CRITERIA; MINIMUM REQUIREMENTS
A.
Mandatory provisions:
Policies or plans issued pursuant to the Minimum Healthcare Protection Act
shall meet the criteria set forth in Section 59A-23B-3B NMSA 1978 regarding
eligibility, managed care provisions and minimum healthcare services to covered
individuals.
B.
Optional
provisions: Policies or plans issued pursuant to the Minimum Healthcare
Protection Act may include the managed care and cost control features provided
in Section 59A-23B-3C NMSA 1978 regarding panels of healthcare service
providers, second opinions before elective surgery, utilization review and a
maximum limit on the cost of healthcare services covered in any calendar year
of not less than $50,000. Pursuant to Section 59A-23B-3D NMSA 1978 a policy or
plan may include additional managed care and cost control provisions that the
superintendent of insurance determines to have the potential for controlling
costs in a manner that does not cause discriminatory treatment of individuals,
families or groups covered by the policy or plan.
C.
Pre-existing conditions:
Pursuant to Section 59A-23B-3E NMSA 1978, notwithstanding any other provisions
of law, a policy or plan shall not exclude coverage for losses incurred for a
pre-existing condition more than six months from the effective date of
coverage. The policy or plan shall not define a pre-existing condition more
restrictively than a condition for which medical advice was given or treatment
recommended by or received from a physician within six months before the
effective date of coverage.
D.
Home healthcare coverage:
(1)
For purposes of the Minimum Healthcare Protection Act and this rule, home
healthcare coverage offered shall include:
(a) services provided by a registered nurse
or a licensed practical nurse;
(b)
health services provided by physical, occupational and respiratory therapists
and speech pathologists;
(c) health
services provided by a home health aide; and
(d) medical supplies, drugs and medicines and
laboratory services, to the extent they would have been covered if provided to
the insured on an inpatient basis.
(2) Home healthcare coverage may be limited
to:
(a) services provided on the written order
of a licensed physician, provided such order is renewed at least every sixty
(60) days;
(b) services provided,
directly or through contractual agreements, by a home health agency licensed in
the state in which the home health services are delivered; and
(c) services, as set forth in 13 NMAC
10.9.9.4.1 [now Paragraph (1) of Subsection D of
13.10.9.9 NMAC], without which the
insured would have to be hospitalized.
(3) A day of home healthcare shall consist of
up to four (4) continuous hours of home healthcare services. Home healthcare
services provided in hourly increments of less than four (4) hours shall be
calculated in proportion to the relationship which the hours of service
provided bear to a four (4) hour day, e.g., two (2) hours of home healthcare
constitute one-half (1/2) day of home healthcare, etc.
(4) Provided, however, that home healthcare
coverage, alone or in combination with inpatient hospitalization coverage,
shall not exceed twenty five (25) days pursuant to the provisions of Section
59A-23B-3B(3)(a) NMSA 1978.
E.
Usual, customary and reasonable
charges:
(1) For purposes of a policy
or plan issued pursuant to the Minimum Healthcare Protection Act and this rule,
a usual, customary and reasonable charge shall be the lesser of:
(a) the customary charge which would be made
by the healthcare services provider for the same service or medical supplies in
the absence of insurance;
(b) the
general level of charge for a comparable service or medical supplies made by
other healthcare service providers in the same geographic area; or
(c) the actual charge made by the healthcare
services provider.
(2)
This provision does not apply to charges of providers who are paid under
contractual arrangements at specified levels of reimbursement as permitted by
Section 59A-23B-3C NMSA 1978.
F.
Enrollment waiting period: A
policy or plan issued pursuant to this rule which does not exclude coverage for
pre-existing conditions as permitted by this rule may impose, in lieu of such
exclusion, a six-month waiting period for enrollment of members of a group who
have pre-existing medical conditions on the effective date of the group's
coverage.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.