New Mexico Register / Volume XXXIII,
Issue 24 / December 27, 2022
This
is an amendment to 13.10.35 NMAC, Sections 2, 3, 7, 8, 9, 10, 11, and 13,
effective 01/01/2024.
13.10.35.2 SCOPE: 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 dental plan. Subject to the
foregoing, this rule applies to a group dental or vision plan offered or sold
to a New Mexico resident under a master policy delivered outside of this state.
[13.10.35.2 NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.3 STATUTORY AUTHORITY: Sections 59A-2-9, 59A-23F-7, and 59A-23G-1 et seq.
NMSA 1978.
[13.10.35.3 NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.7 DEFINITIONS: 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. “Preferred
provider” means a dental or vision care provider,
or group of providers, who contracts with a dental or vision insurance carrier to provide
dental or
vision services to a covered person.]
B. “Earned
premiums” for a reporting year means the premium
received up to the loss ratio measurement date that provided coverage during
that reporting year.
C. “Incurred claims” for a reporting year means
the claims for which services were provided in the reporting year. This includes such claims that were paid in
the reporting year plus unpaid claims reserves for such reporting year.
D. “Loss ratio” means the incurred
claims divided by earned premiums, calculated pursuant to Subsection D of
13.10.35.9 NMAC.
E. “Loss ratio measurement date” means the date as of
which the incurred claims and earned premiums for each reporting
year are determined for the reporting required in Subsection M of 13.10.35.9
NMAC of this rule.
F. “Preferred
provider” means a dental or vision care provider, or
group of providers, who contracts with a dental or
vision insurance
carrier to provide dental or vision services to a covered person.
G. “Reporting year” means a
calendar year during which group or individual dental coverage is provided by a
policy, contract or certificate covering dental services.
H. “Schedule of benefits” means any form that is
part of an insurance policy filed with and approved by the superintendent that contains any of the following
information: coverage levels, cost sharing features, covered services, benefit
maximums and exclusions.
I. “Unpaid claim reserves” for a reporting year means reserves and
liabilities established as of the applicable loss ratio reporting year but were
paid after the reporting year.
[13.10.35.7 NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.8 GENERAL
PROHIBITED POLICY PROVISIONS:
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 which no premium is paid.
B. Riders
and other supplements.
Any rider, amendment, endorsement or other supplement
shall explicitly state which terms of coverage the carrier has amended or supplemented
from the original plan.
C. Exclusions. A plan that includes [a preexisting
condition exclusion] any exclusions shall comply with these
requirements:
(1) each plan application shall include a
prominent notice that the plan includes a preexisting exclusion, and display
either the full text of the exclusion or directions as to how to obtain a copy
of that text.
(2) the carrier shall not enforce a preexisting
condition exclusion if an enrollee renews coverage under a plan offered by the
same carrier.
(3) a plan application shall not request family
member health information unless the family member is also seeking coverage
under the plan; and
(4) a plan may exclude benefits for the replacement of a tooth that the covered
person lost prior to the covered person’s plan effective date unless the
covered person had coverage from a prior carrier.
D. Evidence
of coverage.
Upon request, a carrier shall provide a current or former enrollee evidence of that person’s current or former coverage under a plan.
E. Marketing
of blanket or group coverages.
A carrier shall not sell any blanket coverage to a group that is not described
in Section 59A-23-2 NMSA 1978, or group coverage that is not identified or
described in Section 59A-23-3 NMSA 1978.
F. Arbitration
provisions.
A plan shall not require a covered person to submit a dispute to mediation or
arbitration.
G. Plan
governance.
A covered person’s rights under any plan shall be governed by the terms of the
plan approved by the superintendent, and by applicable state and federal law.
H. Discrimination. No plan shall discriminate in eligibility
for coverage or benefits on the basis of sex, sexual
orientation, gender, race, religion, or national origin.
I. Conversion
privileges.
A carrier shall not offer a conversion plan that is not approved by the
superintendent.
J. Gag
rule.
A plan shall not include, and a carrier shall not otherwise impose, a gag rule
or practice that prohibits a dental or vision service provider from discussing
a treatment option with a covered person.
[13.10.35.8
NMAC - N, 01/01/2022, A, 01/01/2024]
13.10.35.9 GENERAL
STANDARDS FOR POLICIES AND BENEFITS:
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 termination of coverage of the domestic co-insured solely because of the
occurrence of an event specified for termination of coverage of the covered
person, other than nonpayment of premium. In addition, the plan shall provide
that in the event of the covered person’s death, the domestic co-insured of the
covered person, if covered under the plan, shall become a covered person with
the issuance of a new policy and completed agreement.
(3) An individual plan shall protect consumer
rights as follows:
(a) The terms “noncancellable” or
“noncancellable and guaranteed renewable” may only be used in an individual
dental or vision plan if the covered person has the right to continue the
coverage by timely paying premiums, until the age of 65 or until eligibility
for Medicare, whichever is later, during which time the carrier has no
unilateral right to change any provision of the plan.
(b) The term “guaranteed renewable” may only be
used in a plan where the covered person has the right to continue in force, by timely
paying premiums, until the age of 65 or until eligibility for Medicare,
whichever is later, during which period the carrier has no unilateral right to
change any provision of the plan, other than changes in premium rates by
classes.
(c) A plan shall not terminate the coverage of
a covered person except for “good cause,” as follows:
(i) failure of the covered person or subscriber
to pay the premiums and other applicable charges for coverage;
(ii) material failure to abide by the rules, policies or procedures of the plan;
(iii) fraud or misrepresentation affecting
coverage;
(iv) policyholder request for cancellation;
(v) policy term ends; or
(vi) a reason for termination or failure to
renew that the superintendent determines is not objectionable.
(4) If an individual plan covers domestic
co-insureds, the age of the younger insured shall be used as the basis for
meeting the age and durational requirements of the definitions of
“noncancellable” or “guaranteed renewable.” However, this requirement shall not
prevent termination of coverage of the older insured upon attainment of the
stated age so long as the policy may be continued in force as to the younger
spouse to the age or for the durational period specified in the policy.
B. For
individual and group plans.
The following general standards apply to both individual and group plans.
(1) A carrier may not terminate a plan unless it
provides written notice of termination to a covered person one month prior to
the coverage renewal date. A notice of termination shall:
(a) be in writing and dated;
(b) state the reason(s) for termination, with
specific references to the clauses of the dental or vision plan giving rise to
the termination;
(c) state that a covered person’s plan cannot
be terminated because of health status, need for services, race, gender, or sexual orientation of
covered persons under the contract. Age may only be a factor in termination of
coverage as outlined in Paragraph (4) of Subsection A and Paragraph [(7)]
(8) of Subsection B of this section;
(d) state that a covered person who alleges
that an enrollment has been terminated or not renewed because of the covered
person’s health status, need for health care services, race, gender, age or sexual orientation may file a complaint with the
superintendent [of] by phone or on the [Office of Superintendent of
Insurance] OSI’s website; and
(e) state that in the event of termination by
either the covered person or the plan, except in the case of fraud or
deception, the plan shall, within 30 calendar days, return to the covered
person or subscriber the pro rata portion of the money paid to the plan that
corresponds to any unexpired period for which payment had been received
together with amounts due on claims, if any, less any amounts due to the plan,
provided, however, that the superintendent may approve other reasonable
reimbursement practices.
(2) A plan shall include a notice prominently
printed on or attached to the first page of the plan stating that the covered
person shall have the right to return the plan within 30 days of its delivery,
and to have the premium and any required membership fees refunded, if after
examination of the plan the covered person is not satisfied for any reason,
provided no claim has been paid.
(3) If a plan includes a conversion privilege,
the provision shall be captioned, “Conversion Privilege.” The provision shall
specify who is eligible for conversion and the circumstances that govern conversion, or may state that the conversion coverage will
be provided as an approved plan form used by the carrier for that purpose.
(4) If a carrier requires submission of a claim
form as a condition of payment, the carrier, upon receipt of notice of a claim,
shall furnish to the covered person a form to be delivered in the manner
offered by the carrier that is preferred by the covered person. If the carrier
does not furnish a claim form within 15 days after notice of a claim, the
claimant shall be deemed to have complied with the requirement to provide proof
of loss if the notice of claim contains written proof describing the claim,
including the character and extent of the loss of which the claim is made.
Adequate proof of loss must be in the possession of the insurance company at
the time funds are disbursed in payment of claims.
(5) A grace period of at least 10 days for a
monthly premium plan and at least 31 days for any plan billed less frequently
shall be granted for the payment of each premium falling due after the first
premium. During this grace period, the plan shall continue in force.
(6) A carrier shall not use any untrue
statement or inducement not specified in a policy to solicit a prospective plan
enrollee.
(a) A statement shall be deemed untrue if it
does not conform to fact in any respect and would be considered significant to
a person contemplating enrollment with a plan.
(b) Inducements shall meet the requirements of
Subsections G and H of Section 59A-16-17 NMSA 1978.
[(7) A
plan may terminate the coverage of a dependent
due to limiting age for a dependent per the plan’s contracted age limits.
However, a plan must offer coverage to dependents, regardless of age, who are
physically or mentally disabled prior to reaching the limiting age and are
incapable of self-sustaining employment. Coverage for a child who is physically
or mentally disabled prior to reaching the limiting age and incapable of
self-sustaining employment on the date the child would
otherwise age out of coverage shall continue if the child depends on the
covered person for support and maintenance. The plan may require that within 31
days of the date the company receives proof of the child’s incapacity, the
covered person may elect to continue the plan in force with respect to the
child.]
(7) If coverage of dependents is provided, a
carrier shall not terminate coverage of an unmarried dependent by reason of the
dependent's age before the dependent's 26th birthday, regardless of whether the
dependent is enrolled in an educational institution.
(8) A plan may terminate the
coverage of a dependent
due to limiting age for a dependent per the plan’s contracted age limits.
However, a plan must offer coverage to dependents, regardless of age, who are
physically or mentally disabled prior to reaching the limiting age and are
incapable of self-sustaining employment. Coverage for a child who is physically
or mentally disabled prior to reaching the limiting age and incapable of
self-sustaining employment on the date the child would
otherwise age out of coverage shall continue if the child depends on the
covered person for support and maintenance. The plan may require that within 31
days of the date the company receives proof of the child’s incapacity, the
covered person may elect to continue the plan in force with respect to the
child.
C. For
group coverage.
[A group plan shall comply with Sections 8, 9, 11, and 12 of 13.10.5 NMAC,
and Subsection D of 13.10.5.10 NMAC]. A group plan that offers dental or
vision coverage shall comply with all sections of this rule.
D. Prior approval of forms required.
A carrier shall not issue, deliver, or use a form associated with applicable
dental and vision plans, unless and until such form has been filed with and
approved by the superintendent.
E. Prior approval of rates required. A carrier
shall not use rates or modified rates for dental and vision plans unless and
until such rates are filed with and approved by the superintendent.
F. Minimum loss ratios for group and
individual dental plans. Benefits dental plans shall be subject to
a sixty-five percent minimum loss ratio requirement.
G. Minimum loss ratios for group and
individual vision plans. Benefits under vision plans shall be
subject to a fifty-five percent minimum loss ratio requirement.
H. Rate filing requirements.
Each carrier providing dental or vision insurance must
provide an actuarial analysis in an actuarial memorandum, certified by a
qualified actuary, for each individual or group plan sold in New Mexico. Experience data may be
aggregated for those policies or certificates that are rated together due to
noncredible experience. A rate filing
for a plan which provides both dental and vision benefits under the same policy
must provide information in the actuarial memorandum and other supporting
documentation to separately identify and support the premiums attributed to the
dental and vision coverages. The superintendent shall post on its
website requirements for filing actuarial memorandums and rates for rate filing
requests. These requirements may differ for:
(1) dental
and vision plans;
(2) individual,
small group, and large group dental and vision plans;
(3) dental
and vision plans sold on and off the health benefits exchange.
I. Calculating the loss ratio for individual
and group dental and vision plans. The loss ratio is
calculated as the ratio of the numerator to the denominator, as defined in
Paragraphs (1) and (2) below. The loss
ratio shall be calculated separately for dental and vision coverages, even if
both dental and vision benefits are included in a single policy or contract.
(1) Numerator. The numerator is
equal to the incurred claims for the loss ratio reporting year.
(2) Denominator. The denominator is
the earned premiums for the loss ratio reporting year.
J. Rate revisions. The
following requirements shall apply to rate revision requests: With respect to
filing rate revisions for a previously approved form, or a group of previously
approved forms combined for experience, benefits may be deemed reasonable in
relation to premiums provided the revised rates meet the minimum loss ratio
requirements of Subsections F or G of this rule, as applicable, and most
current standards applicable to rate filings as prescribed by the
superintendent, pursuant to Subsection I above based on actual experience and
expected experience in the rating period,
K. Rates for new plans. The
following requirements shall apply to rates for dental and vision plans not
previously offered for sale in New Mexico: with respect to filing rates for a
new plan, benefits may be deemed reasonable in relation to premiums provided
the proposed rates meet the minimum loss ratio requirements of this rule, as
applicable, and most current standards applicable to rate filings as prescribed
by the superintendent, based on expected experience in the first three years.
L. Disapproval of forms and rates.
The superintendent shall issue a disapproval:
(1) if the benefits provided therein
are unreasonable in relation to the premium charged. For purposes of this rule, a dental or vision
plan that meets the minimum loss ratio requirements will be considered to have
benefits that are reasonable in relation to the premium charged;
(2) If there is misrepresentation of
the benefits, advantages, conditions or terms of any
plan or if the plan is characterized as more favorable to the covered person
than the actual terms of the plan, such as naming coverage for services or
conditions for which the primary forms of treatment are listed as exclusions;
(3) If there are false or misleading
statements;
(4) If the name or title of a form is
misrepresenting the true nature thereof; or
(5) If the plan contains provisions
that are contrary to law, discriminatory, deceptive, unfair, impractical, unnecessary or unreasonable.
M. Disclosure
and reporting compliance with minimum loss ratio
requirements. By July 31st following each reporting year,
carriers providing dental or vision benefit coverage
must submit to the superintendent an actuarial memorandum prepared by a
qualified actuary, which discloses the actual loss ratio for each plan, form or
certificate subject to this rule. The annual filing shall, at a minimum,
include rates, rating schedules, and supporting documentation, including ratios
of incurred claims to earned premiums for each calendar year since issue.
Information shall be in the form prescribed by the superintendent and shall
demonstrate that each plan complies with the minimum loss ratio standards.
Carriers that provide dental or vision insurance coverage that acquire a line
or block of business from another carrier during a reporting year are
responsible for submitting the required information and reports for the assumed
business, including for that part of the reporting year that preceded the
acquisition.
(1) General. Carriers shall meet the minimum loss ratio
established, and in the manner calculated, under this section of the rule.
(2) Aggregation. Experience data may
be aggregated for those policies or certificates that are rated together due to
noncredible experience.
(3) Measurement period.
Compliance with the minimum loss ratio shall be measured over the last three
calendar years of experience and for each calendar year of experience utilized
in the rate determination process, but never less than the last three calendar
years, after the
initial transition period (2024 to 2026). The initial measurement period shall
be calendar year 2024; the second measurement year shall be calendar years 2024
and 2025; the third measurement period shall be calendar years 2024, 2025 and
2026. Each year thereafter, the subsequent calendar year shall be added to the
rolling three-year period and the oldest calendar year shall be removed. For
example, the fourth measurement period shall be calendar years 2025, 2026, and
2027.
(4) Frequency. Loss ratios shall be
calculated annually by carriers that issue vision or dental plans specified in
this rule, beginning with the 2024 reporting year.
(5) Timeline. The
evidence of compliance with the minimum loss ratio requirements shall be filed
with the superintendent by July 31 of the year following the reporting year.
For noncredible blocks of business, the company may request a waiver of the
requirement. The request shall be made annually and must be accompanied by a
letter indicating the nature of the filing, the type of plan, and the reason
for the request.
(6) Methodology. For existing plans,
actual loss ratios shall be calculated using company historical claim data
including an estimate for claims incurred but not reported, as appropriate.
(a) The superintendent shall assure that
reserves are reasonable and based on sound actuarial principles with respect to
the aggregate dollar amount of reserves for claims that are incurred but not
yet paid, and for claims that are incurred but not yet reported.
(b) The claims will be reported for each
calendar year of experience utilized in the rate determination process, but
never less than the last three years after the third year of experience is
available.
(c) A plan shall be deemed to comply with the
purposes of this section if the expected losses in relation to expected
premiums over the entire period for which the plan is rated comply with the requirements of
this section and either of the following applies:
(i) For
policies or certificates that have been in force for three years or more, for
the last three years, the ratio of incurred losses to earned premiums is
greater than or equal to the minimum loss ratios established by this rule.
(ii) For policies or certificates that
have been in force for fewer than three years, the expected third-year loss
ratio can be demonstrated to be greater than or equal to the minimum loss
ratio.
(7) Credibility. The
certifying actuary shall include a statement related to the credibility of the
data and the methodology used to determine such credibility in accordance with
the applicable actuarial standards of practice.
(8) Compliance with minimum loss ratios.
Each carrier shall submit to the superintendent an exhibit showing the
calculation of the applicable loss ratios and:
(a) a statement signed by a qualified
actuary that the minimum loss ratio requirements have been met; or
(b) a rate filing to justify the rates,
revise rates, modify benefits through a benefit endorsement or to return excess
premium.
(9) Corrective action plan. The
superintendent may require a corrective action plan to return excess premiums
or increase benefits if the minimum loss ratio requirements are not met.
(a) A carrier shall not return excess
premiums per the above guidelines, until the carrier files a corrective action
plan and obtains approval of such plan by the superintendent.
(b) If, in the opinion of the
superintendent, a plan’s failure to meet the minimum loss ratio requirements is
due to unusual reserve fluctuations, economic conditions, or other nonrecurring
conditions, the superintendent may elect not to issue a corrective action plan.
Any such exemption shall be in writing.
[13.10.35.9
NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.10 DENTAL
PLANS:
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 supplies.
(2) “Dental
service” means a professional service rendered by a person duly licensed under
the laws of this state to practice dentistry or dental therapy, or dental
hygienists or dental hygienists certified in collaborative practice and any
service constituting the practice of dentistry under state law.
C. Required
minimum benefits. A
dental plan shall, at a minimum, provide each covered person benefits for the
following dental services and dental supplies.
(1) Diagnostic services. A dental plan shall
cover the following diagnostic services [with a waiting period of no longer
than six consecutive months] with no waiting period:
(a) one clinical oral examination twice per plan year;
(b) clinical oral examinations when performed
as a part of an emergency service to relieve pain and suffering.
(2) Radiology services. A dental plan shall
cover the following radiology services with a waiting period of no longer than
six consecutive months:
(a) Bitewing x-rays at least once a year unless
greater frequency is deemed medically necessary; and
(b) Panoramic films or an intraoral-complete
series, at least once every five consecutive years.
(3) Preventive services. A
dental plan shall cover the following services with no waiting period, subject
to the following limitations:
(a) Prophylaxis.
A dental plan shall cover at least two prophylaxis services every plan year.
(b) Fluoride
treatment. A dental plan shall cover at least one fluoride treatment per
calendar year furnished in a health care setting for children up to 14 years
old or older as medically necessary.
(c) Molar
sealants. A dental plan shall cover one treatment of molar sealant per tooth
every five consecutive years as medically necessary. A dental plan may exclude
coverage where an occlusal restoration has been completed on the tooth. A
dental plan may apply a waiting period of six consecutive months for medically
necessary sealants.
(4) Cavities.
A dental plan shall cover necessary fillings for cavities. A dental plan may not apply a waiting
period for cavity fillings.
[(5) Craniomandibular and temporomandibular
joint disorders. A dental plan sold in conjunction with a qualified health plan
shall cover the diagnosis and treatment of craniomandibular and
temporomandibular joint disorders, if such coverage is not offered by the
qualified health plan.]
D. Maximum
out-of-pocket.
To be certified for sale on New Mexico’s health insurance exchange, a dental
plan shall comply with any federally mandated maximum out-of-pocket limits
for dental plans.
[13.10.35.10
NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.11 VISION
PLANS:
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 plan limitation;
(2) “covered services” means services that are
reimbursable by a vision plan vision plan to a vision care provider subject to
any deductible, copayment, coinsurance, or other plan limitation;
(3) “materials” means ophthalmic devices,
including;
(a) lenses;
(b) frames;
(c) contact lenses; and
(d) spectacle or contact lens treatments and
coatings;
(4) “noncovered materials” means materials that
are not covered by a vision plan;
(5) “noncovered services” means services that
are not covered by a vision plan.
(6) “vision services” means services provided
by a vision care provider;
(7) “vision plan” is a policy, contract, agreement or arrangement under which an entity undertakes to
reimburse claims for the cost of vision services or vision materials; and
(8) “vision care provider” means an individual
licensed under state law as an optometrist or ophthalmologist.
C. Required
minimum benefits.
A vision plan shall provide each covered person benefits for the following
vision services and vision materials. [A pediatric vision plan sold in
conjunction with a qualified health plan shall provide vision coverage mandated
by law for the qualified health plan, or the benefits mandated by this rule,
whichever are most favorable to the member.]
(1) Examinations. At least once every consecutive two-year
period for adults and once every 12-month consecutive period for children under
the age of 19, a comprehensive vision examination. The comprehensive vision
examination shall include a complete analysis of the eyes and related
structures, as appropriate, to determine the presence of vision problems or
other abnormalities.
(2) Lenses. If the vision examination indicates that
corrective lenses are necessary, each covered person is entitled to necessary
frames and lenses, including coverage for single vision, bifocal, trifocal, and
lenticular as medically necessary and up to the stated benefit limit of the plan. This benefit may be limited to once each
two-year consecutive period, unless medical necessity requires increased
frequency, and may be subject to a maximum one-month waiting period.
(3) Contact lenses shall be covered as follows:
(a) Medically necessary contact lenses shall be
covered in full, up to a benefit maximum, subject to prior authorization from
the vision plan [if dispensed or provided by an in-network provider or
vendor].
(b) A vision plan shall provide an elective contact
lens allowance up to the stated benefit limit of the plan.
(c) This benefit may be limited to once each
12-month consecutive period and may be subject to a maximum one-month waiting
period.
D. Noncovered
services and materials.
A vision plan may exclude coverage for the following services and materials:
(1) any that are not medically necessary;
(2) any that were not obtained in compliance
with the requirements of the vision plan;
(3) any medical or surgical treatment of the
eyes;
(4) vision therapy; and
(5) two pairs of glasses in lieu of bifocals.
[13.10.35.11
NMAC - N, 01/01/2022; A, 01/01/2024]
13.10.35.13 COVERAGE
DOCUMENTATION:
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 summary of benefits on
behalf of the carrier.] 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 summary
of benefits on behalf of the carrier.
(2) The policy, certificate of coverage or [summary]
schedule of benefits shall
include a clear and complete statement of:
(a) the covered services, supplies and
materials;
(b) any limitations or exclusions including any
charge, deductible or copayment feature;
(c) [where
and in what manner information is available as to how services may be obtained;]
cost-sharing
features must be written from the perspective of the insured;
(d) [a clear
and understandable description of the method for resolving a covered person’s
complaint.] where
and in what manner information is available and as to how services may be
obtained;
(e) [conditions for renewal and reinstatement;] a clear and understandable description of the method for resolving
a covered person’s complaint;
(f) [procedures
for filing claim]
a reinstatement provision which states that when premium is not paid within
the applicable grace period, a subsequent acceptance of premium by the insurer
or their agent without requiring an application for reinstatement, shall
reinstate the policy. However, if the insurance company requires an application
for reinstatement and issues a conditional receipt for the premium tendered,
the policy will be reinstated upon approval of such application, lacking such
approval, upon the 30th day following the date of such conditional receipt
unless the insurance company has previously notified the insured in writing of
its disapproval of such application;
(g) [a statement of the amounts payable to the carrier by a covered
person and the times at which the amounts shall be paid;] a clear and understandable description
of the conditions for renewal;
(h) [the period during which the plan is effective; and]
procedures for filing claims;
(i) [on the front page, the identity
of the carrier.] statement
of the amounts payable to the carrier by a covered person and the times at which
the amounts shall be paid;
(j) the period during which the plan is
effective; and
(k) on the front page, the identity of the
carrier.
(3) Any subsequent change in coverage or
premium shall be explained in a separate document delivered to the covered
person.
(4) PPO and indemnity plans cannot be combined
and must be submitted in separate product filings.
B. Notice
required. If the company sends a separate
schedule of benefits to the insured, [The] the following
language shall be provided [in a summary of benefits] in the separately
issued schedule of benefits:
READ
YOUR PLAN CAREFULLY - THIS BENEFITS SUMMARY PROVIDES A VERY BRIEF DESCRIPTION
OF THE IMPORTANT FEATURES OF YOUR PLAN. THIS IS NOT THE INSURANCE CONTRACT.
YOUR FULL RIGHTS AND BENEFITS ARE EXPRESSED IN THE ACTUAL PLAN DOCUMENTS THAT
ARE AVAILABLE TO YOU [UPON YOUR REQUEST TO US].
C. Contact
information. The policy, certificate [or summary of benefits] and schedule of benefits, if issued
separately, shall
state the plan’s contact information and the website and phone number [of
the office of superintendent of insurance] for OSI.
D. Insurance
cards. Basic consumer
information, including the phone number and website of the insurer’s consumer
assistance bureau, shall be included on all newly-issued
physical or
digital insurance cards. Carriers may issue digital cards,
but shall provide a physical card upon the request of the consumer.
[13.10.35.13
NMAC - N, 01/01/2022; A, 01/01/2024]
History
of 13.10.35 NMAC: [RESERVED]