13.10.2 NMAC

This rule was filed as 13 NMAC 10.2.

TITLE 13 INSURANCE

CHAPTER 10 HEALTH INSURANCE

PART 2 MOTHERS AND NEWLY BORN CHILDREN HEALTH SECURITY

13.10.2.1 ISSUING AGENCY [Public Regulation Commission] New Mexico Department of Insurance.

[3/1/96; Recompiled 11/30/01]

13.10.2.2 SCOPE: This rule applies to any person, insurer, health maintenance organization, fraternal benefit society, nonprofit health care plan, New Mexico comprehensive health insurance pool, or health insurance alliance, transacting health insurance or providing health care services as defined herein, in this state.

[3/1/96; Recompiled 11/30/01]

13.10.2.3 STATUTORY AUTHORITY: Authority for this rule derives from the superintendent’s powers under Sections 59A-2-9, 59A-16-4, 59A-16-5, 59A-16-18, 59A-16-20, 59A-18-14, 59A-22-34, 59A-22-36, 59A-23B-3, 59A-44-30, 59A-44-31, 59A-46-38, 59A-47-25, 59A-54-13, and 59A-56-7 NMSA 1978.

[3/1/96; Recompiled 11/30/01]

13.10.2.4 DURATION: Permanent.

[3/1/96; Recompiled 11/30/01]

113.10.2.5 EFFECTIVE DATE: This rule shall take effect March 1, 1996 [unless a later date is cited at the end of a section].

[3/1/96; Recompiled 11/30/01]

13.10.2.6 OBJECTIVE: The objectives of this rule are to ensure that necessary postpartum health care is provided to newly born children and their mothers in the safest manner and at the earliest possible time, and to regulate trade practices in the insurance business and related businesses by prohibiting unfair or deceptive acts or practices.

[3/1/96; Recompiled 11/30/01]

13.10.2.7 DEFINITIONS:

A. As used in this rule, the following terms have the meanings given in the cited section of the New Mexico Statutes Annotated 1978:

(1) Approved health plans, Section 59A-56-3(B) NMSA 1978;

(2) Fraternal benefit society, Section 59A-44-1 NMSA 1978;

(3) Health insurance alliance, Section 59A-56-3(A) NMSA 1978;

(4) Health maintenance organization, Section 59A-46-2(M) NMSA 1978;

(5) Insurer, Section 59A-1-8 NMSA 1978;

(6) Insurance Code, Section 59A-1-1 NMSA 1978;

(7) Superintendent, Section 59A-1-12 NMSA 1978;

(8) Health facility, Section 50-23-3(E) NMSA 1978.

B. As used in this rule, the following terms have the meanings given here:

(1) “Attending physician” means the attending obstetrician, pediatrician or other physician attending the mother or newly born child.

(2) “Inpatient” means a patient admitted for treatment to a health facility.

(3) “Maternity benefits” means coverage for prenatal, intrapartum, perinatal or postpartum care.

(4) “Medically necessary” means that the patient’s health, in the opinion of the attending physician, would be adversely affected by lack of appropriate treatment.

(5) “New Mexico comprehensive health insurance pool” means an entity organized pursuant to Section 59A-54-4(A) NMSA 1978.

(6) “Nonprofit health care plan” means a health care plan organized pursuant to Section 59A-47-4 NMSA 1978.

(7) “Pool policy” means a health insurance policy delivered or issued for delivery in this state pursuant to the Comprehensive Health Insurance Pool Act, Article 54 NMSA 1978.

[3/1/96; Recompiled 11/30/01]

13.10.2.8 INDIVIDUAL AND GROUP HEALTH INSURANCE POLICIES:

A. All individual and group health insurance policies delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 8.1 of this section [now Subsection A of 13.10.2.8 NMAC], an individual or group insurance policy delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide for coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

C. Postpartum care in the home shall be made in accordance with accepted maternal and neonatal physician assessments, by a person with appropriate licensure, training and experience to provide postpartum care. Services provided by such person shall include, but not be limited to, parent education, assistance and training in breast and bottle feeding, and the performance of any necessary and appropriate clinical tests.

D. Postpartum care in the home shall consist of a minimum of three home visits, unless one or two home visits are determined to be sufficient by the attending physician or person with appropriate licensure, training and experience to provide postpartum care, and the mother. The home visits shall be conducted within the time period ordered by the attending physician or person with appropriate licensure, training and experience to provide postpartum care.

E. Each insurer providing maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the insurer and to her attending physician, upon receipt by the insurer of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 8.5 [now Subsection E of 13.19.2.8 NMAC], each insurer providing maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the insurer, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the insurer will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.9 MINIMUM HEALTHCARE PROTECTION ACT POLICIES AND BENEFIT PLANS:

A. All healthcare policies or healthcare benefit plans offered under the authority of the Minimum Healthcare Protection Act delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 9.1 of this section [now Subsection A of 13.10.2.9 NMAC], an approved healthcare policy or healthcare benefit plan offered under the authority of the Minimum Healthcare Protection Act delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide for coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each insurer providing coverage under the authority of the Minimum Healthcare Protection Act through a healthcare policy or healthcare benefit plan which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the insurer and to her attending physician, upon receipt by the insurer of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 9.5 [now Subsection E of 13.10.2.9 NMAC], each insurer providing coverage under the authority of the Minimum Healthcare Protection Act through a healthcare policy or healthcare benefit plan which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the insurer, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the insurer will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.10 HEALTH MAINTENANCE ORGANIZATION CONTRACTS:

A. All individual and group health maintenance organization contracts delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 10.1 of this section [now Subsection A of 13.10.2.10 NMAC], an individual or group health maintenance organization contract delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide for coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each health maintenance organization which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother enrolled in the health maintenance organization and to her attending physician, upon receipt by the health maintenance organization of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 10.5 [now Subsection E of 13.10.2.10 NMAC], each health maintenance organization which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the health maintenance organization, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the health maintenance organization will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.11 FRATERNAL BENEFIT SOCIETY CONTRACTS:

A. All fraternal benefit society contracts delivered or issued for delivery in this state which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 11.1 of this section [now Subsection A of 13.10.2.11 NMAC], a fraternal benefit society contract delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide for coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each fraternal benefit society which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the fraternal benefit society and to her attending physician, upon receipt by the fraternal benefit society of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 11.5 [now Subsection E of 13.10.2.11 NMAC], each fraternal benefit society which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the fraternal benefit society, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the fraternal benefit society will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.12 NONPROFIT HEALTH PLAN CONTRACTS:

A. All subscriber contracts of a nonprofit health care plan delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of sub-section 12.1 of this section [now Subsection A of 13.10.2.12 NMAC], a subscriber contract of a nonprofit health care plan delivered or issued for delivery in this state that provides coverage for postpartum care for a mother and her newly born child in the home shall not be required to provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each nonprofit health care plan which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the nonprofit health care plan and to her attending physician, upon receipt by the nonprofit health care plan of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 12.5 [now Subsection E of 13.10.2.12 NMAC], each nonprofit health care plan which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the nonprofit health care plan, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the nonprofit health care plan will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.13 NEW MEXICO COMPREHENSIVE HEALTH INSURANCE POOL POLICIES:

A. All pool policies delivered or issued for delivery in this state by the New Mexico comprehensive health insurance pool and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 13.1 of this section [now Subsection A of 13.10.2.13 NMAC], a pool policy delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide for coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each insurer providing coverage through the New Mexico comprehensive health insurance pool under a policy which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the insurer and to her attending physician, upon receipt by the insurer of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 13.5 [now Subsection E of 13.10.2.13 NMAC], each insurer providing coverage through the New Mexico comprehensive health insurance pool under a policy which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the insurer, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the insurer will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.14 HEALTH INSURANCE ALLIANCE CONTRACTS:

A. All approved health plans offered through the New Mexico health insurance alliance delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.

B. Notwithstanding the provisions of subsection 14.1 of this section [now Subsection A of 13.10.2.14 NMAC], an approved health plan offered through the New Mexico health insurance alliance delivered or issued for delivery in this state that provides coverage for postpartum care to a mother and her newly born child in the home shall not be required to provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.

E. Each insurer providing coverage through the New Mexico health insurance alliance under a policy which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the insurer and to her attending physician, upon receipt by the insurer of notification of the diagnosis of pregnancy of the expectant mother.

F. In addition to the notification provided in subsection 14.5 [now Subsection E of 13.10.2.14 NMAC], each insurer providing coverage through the New Mexico health insurance alliance under a policy which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the insurer, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the insurer will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.

[3/1/96; Recompiled 11/30/01]

13.10.2.15 INCENTIVES OR PENALTIES PROHIBITED: No person, insurer, health maintenance organization, fraternal benefit society, nonprofit health care plan, New Mexico comprehensive health insurance pool, or health insurance alliance, transacting health insurance or providing health care services, as defined herein, in this state, shall provide, directly or indirectly, any financial incentive or disincentive, or grant or deny any special favor or advantage of any kind or nature whatsoever, to any person to encourage or cause early discharge of a hospital inpatient from postpartum care. Notwithstanding the above, this section does not prohibit use of prospective payment systems including, but not limited to, capitation and diagnostic related groupings, that are designed to promote efficiency in appropriate health care delivery.

[3/1/96; Recompiled 11/30/01]

13.10.2.16 PENALTIES: In addition to any other penalty provided by law or rule, violation of the provisions of this rule is subject to penalties for violation of the Insurance Code.

[3/1/96; Recompiled 11/30/01]

13.10.2.17 SEVERABILITY: 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, the remainder of the rule, or the applicability of such provisions to other persons or circumstances, shall not be affected.

[3/1/96; Recompiled 11/30/01]

HISTORY OF 13.10.2 NMAC: [RESERVED]