TITLE
13 INSURANCE
CHAPTER
10 HEALTH INSURANCE
PART
29 DEFINITIONS
13.10.29.1 ISSUING AGENCY: Office of Superintendent of Insurance (OSI),
Life and Health (L&H).
[13.10.29.1
NMAC - N, 10/01/2018]
13.10.29.2 SCOPE: This rule applies to all health insurance
carriers, including health maintenance organizations, individual health plans,
group and blanket health plans, provider service networks and nonprofit
healthcare plans that offer or administer health benefits plans, including
health benefits plans and managed health care plans subject to the insurance
laws and regulations of this state.
[13.10.29.2
NMAC - N, 10/01/2018]
13.10.29.3 STATUTORY AUTHORITY: Sections 59A-2-8, 59A-2-9, 59A-7-3, 59A-18-2,
59A-18-13.2, 59A-18-13.3, 59A-18-16.2, 59A-22-1 et seq., 59A-23-2, 59A-23-3,
and 59A-46-1 et seq. NMSA 1978.
[13.10.29.3
NMAC - N, 10/01/2018]
13.10.29.4 DURATION: Permanent.
[13.10.29.4
NMAC - N, 10/01/2018]
13.10.29.5 EFFECTIVE DATE: October 1, 2018, unless a later date is cited
at the end of a section.
[13.10.29.5
NMAC - N, 10/01/2018]
13.10.29.6 OBJECTIVE: The purpose of this rule is to
standardize the definitions utilized for rules applicable to health insurance
carriers as defined by the scope of this rule in 13.10.29.2 NMAC.
[13.10.29.6
NMAC - N, 10/01/2018]
13.10.29.7 DEFINITIONS:
A. Terms beginning with the letter “A”:
(1) “Accrued liability” means
liabilities established on the date an injury is sustained or an illness
commences.
(2) “Ambulance service” means any
transportation service designated and used or intended to be used for the
transportation of sick or injured persons.
(3) “Ambulatory surgical center” means a
facility where health care providers perform surgeries, including diagnostic
and preventive surgeries that do not require hospital admission.
(4) “Appointment waiting time” means the time
from the initial request for health care services by a covered person or the
covered person’s treating provider to the earliest date offered for the appointment
for services inclusive of the time for obtaining authorization from the health
insurance carrier or completing any other condition or requirement of the
carrier or its participating providers.
(5) “Authorized representative of a
covered person”
means an individual selected and authorized in writing by a covered person to
represent the covered person’s interests in matters related to the provision of
services under a health benefits plan.
Health care professionals and health insurance agents and brokers may
serve as authorized representatives of covered persons.
(6) “Authorized representative of a
health insurance carrier” means an individual or organization that is
selected by the insurance company to represent its interests in an aspect of the
regulatory or hearing process.
B. Terms beginning with the letter “B”:
(1) “Behavioral health services” means
assessment, diagnosis, treatment or counseling in the context of a professional
relationship to assist an individual or group alleviate behavioral symptoms,
conditions or disorders, including mental health diagnoses and substance use
disorders, as well as other services to address developmental disability or
developmental delay.
(2) “Blanket health insurance” is a form of
health insurance covering special groups of not fewer than 10 persons that
meets the criteria outlined in Section 59A-23-2 NMSA 1978.
(3) “Business day” means a
consecutive 24-hour period, excluding weekends or state holidays.
C. Terms beginning with the letter “C”:
(1) “Certificate” means any
certificate issued under an individual or group accident and health insurance
policy that has been delivered or issued for delivery in this state, regardless
of the state in which the policyholder is domiciled.
(2) “Certification of service” means a
determination by a health insurance carrier that a health care service
requested by a health care professional or covered person has been reviewed
and, based upon the information available, is a covered benefit and meets the
carrier’s requirements for medical necessity, appropriateness, health care
setting, level of care and effectiveness, and the requested health care service
is therefore approved. The certification
of service can take place following the health carrier’s utilization review
process.
(3) “Certified nurse-midwife” means any person
who is licensed by the board of nursing as a registered nurse and who is
licensed by the New Mexico department of health as a certified nurse-midwife.
(4) “Certified nurse practitioner” means a
registered nurse whose qualifications are endorsed by the board of nursing for
expanded practice as a certified nurse practitioner and whose name and
pertinent information are entered on the list of certified nurse practitioners
maintained by the board of nursing.
(5) “Claim” means a request
from a provider for payment for health care services rendered.
(6) “Clinical peer” means a
physician or other health care professional who holds a similar non-restricted
license in a state or territory of the United States and in the same or similar
specialty as typically manages the medical condition, procedure, or treatment
under review.
(7) “Clinical review criteria” means the
written screening procedures, decision abstracts, clinical protocols and
practice guidelines used by a health insurance carrier to determine the medical
necessity and appropriateness of health care services.
(8) “Co-insurance” is a
cost-sharing method that requires a covered person to pay a stated percentage
of medical or pharmaceutical expenses after the deductible amount, if any, is
paid; co-insurance rates may differ for different types of services under the
same health benefits plan.
(9) “Copayment” is a
cost-sharing method that requires a covered person to pay a fixed dollar amount
when a medical or pharmaceutical service is received, with the health insurance
carrier paying the allowed balance; there may be different copayment amounts
for different types of services under the same health benefits plan.
(10) “Continuous quality improvement” means ongoing
and systematic efforts to measure, evaluate, and improve a health insurance
carrier’s processes and procedures in order to continually improve the quality
of health care services provided to covered persons.
(11) “Cost-sharing” means a
copayment, co-insurance, deductible, or any other form of financial obligation
of a covered person other than premium or share of premium, or any combination
of any of these financial obligations as defined by the terms of the health
benefits plan.
(12) “Covered benefits” means those
health care services to which a covered person is entitled under the terms of a
health benefits plan.
(13) “Covered person” or “enrollee” means a subscriber,
policyholder or subscriber’s enrolled dependent or dependents, or other
individual participating in a health benefits plan.
(14) “Credentialing” means the
process of obtaining, verifying and evaluating information about a provider
when the provider applies to become a participating provider within a health
insurance carrier’s network.
D. Terms beginning with the letter “D”:
(1) “Day” or “Days” shall be interpreted as
follows, unless otherwise specified:
(a) one to five days
means only working days and excludes weekends and state holidays; and
(b) six or more days
means calendar days, including weekends and state holidays.
(2) “Deductible” means a fixed
dollar amount that a covered person may be required to pay during a benefit period
before the health insurance carrier begins payment for covered benefits; health
benefits plans may have both individual and family deductibles and separate
deductibles for specific services.
(3) “Designated rating area” means a
geographic unit designated by the superintendent and used by insurers to
determine health benefits plan premiums.
E. Terms beginning with the letter “E”:
(1) “Emergency care” means health
care procedures, treatments or services delivered to a covered person after the
sudden onset of what reasonably appears to be a medical or behavioral health
condition that manifests itself by symptoms of sufficient severity, including
severe pain, that the absence of immediate medical attention could be expected
by a reasonable layperson to result in jeopardy to a person’s physical or
mental health or to the health or safety of a fetus or pregnant person, serious
impairment of bodily function, serious dysfunction of a bodily organ or part or
disfigurement to a person;
(2) “Enrollee” or “covered person” means a subscriber, policyholder or subscriber’s enrolled dependent
or dependents, or other individual participating in a health benefits plan.
(3) “Essential community provider (ECP)” means a
provider as defined in 45 C.F.R. §156.235(c).
(4) “Evidence of coverage (EOC)” means a specific
document containing a clear,
conspicuous, concise and legible written statement of the essential features
and services covered by a health benefits plan given to the covered person by
the health insurance carrier or group contract holder, which may include a
separate summary of benefits as defined in Paragraph (7) of Subsection S of
this section. The evidence of coverage
may serve as a covered person’s certificate as defined in Paragraph (1) of
Subsection C of this section.
(5) “Exception” or “exclusion” means any provision in a
health benefits plan whereby coverage for a specific hazard, condition, or
situation is excluded entirely. It is a
statement of a risk or risks not assumed by the health insurance carrier under
the plan.
(6) “Exchange”
means the New Mexico health insurance exchange, composed of an exchange for the
individual market and a small business health options program (SHOP) exchange
under a single governance and administrative structure. Also known as the health
insurance marketplace.
F. Terms beginning with the letter “F”:
(1) “Facility” means an entity
providing a health care service, including:
(a) a general,
specialized, psychiatric or rehabilitation hospital;
(b) an ambulatory
surgical center;
(c) a cancer
treatment center;
(d) a birth
center;
(e) an
inpatient, outpatient or residential drug and alcohol treatment center;
(f) a
laboratory, diagnostic or other outpatient medical evaluation or testing
center;
(g) a health
care provider’s office or clinic;
(h) an urgent
care center; or
(i) any other therapeutic health care setting.
(2) “Federally
qualified health center (FQHC)” means an entity as defined in 42 C.F.R.
§405.2401.
(3) “FDA” means the United States food and
drug administration.
G. Terms beginning with the letter “G”: “Group
health insurance” means a form of health insurance covering groups of
persons, with or without their dependents, and issued upon the criteria
outlined in Section 59A-23-3 NMSA 1978.
H. Terms beginning with the letter “H”:
(1) “Health benefits plan” means a policy
or agreement entered into, offered or issued by a health insurance carrier to
provide, deliver, arrange for, pay for or reimburse any of the costs of health
care services.
(2) “Health care professional” means a
physician or other health care practitioner, including a pharmacist or
practitioner of the healing arts, who is licensed, certified or otherwise
authorized by the state to provide health care services consistent with state
law.
(3) “Health care service” means a
service, supply or procedure for the diagnosis, prevention, treatment, cure or
relief of a health condition, illness, injury or disease, including, to the
extent covered by the health benefits plan, a physical or behavioral health
service.
(4) “Health insurance carrier,” “health
carrier,”
“carrier” or “health insurer” means an entity subject to the insurance laws and
regulations of this state, including a health insurance company, a health
maintenance organization, a hospital and health services corporation, a
provider service network, a non-profit health care plan or any other entity
that contracts or offers to contract, or enters into agreements to provide,
deliver, arrange for, pay for or reimburse any costs of health care services,
or that provides, offers health benefits plans or managed health care plans in
this state.
(5) “Health maintenance organization
(HMO)”
is as defined in Subsection N of Section 59A-46-2 NMSA 1978.
(6) “Hospital” means a
facility offering inpatient services, nursing and overnight care for three or
more individuals on a 24-hours-per-day, seven-days-per-week basis for the
diagnosis and treatment of physical, behavioral or rehabilitative health conditions.
I. Terms beginning with the letter
“I”: “Initial
determination” means a formal written disposition by a health insurance
carrier affecting a covered person’s rights to benefits, including full or partial
denial of a claim or request for coverage or its initial administrative
decision pursuant to the grievance procedures set forth at 13.10.17 NMAC.
J. Terms beginning
with the letter “J”: [RESERVED]
K. Terms beginning with the letter “K”: [RESERVED]
L. Terms beginning with the letter “L”:
(1) “Limitation”
means any provision that restricts coverage under a health benefits plan other
than an exception, exclusion or reduction.
(2) “Limited
benefits plan” means a health benefits plan offered or marketed as
supplemental health insurance coverage that pays specified amounts according to
a schedule of benefits to defray the costs of care, services or cost-sharing
amounts not covered by a major medical plan.
“Limited benefits plan” does not include a short-term, limited-duration
plan.
M. Terms beginning with the letter “M”:
(1) “Major
medical plan” or “comprehensive
plan” means a health benefits plan, other than a limited benefits
plan, that provides fully-insured, expense-based coverage, including a
short-term, limited duration plan; a qualified health plan; a managed health
care plan; a student health plan or a high-deductible or catastrophic plan.
(2) “Managed care” means a system
or technique(s) generally used by third-party payors
or their agents to affect access to and control payment for health care
services. Managed care techniques most
often include one or more of the following:
(a) prior,
concurrent and retrospective review of the medical necessity and
appropriateness of services or site of services;
(b) contracts
with selected health care providers;
(c) financial
incentives or disincentives for covered persons to use specific providers,
services, prescription drugs or service sites;
(d) controlled access
to and coordination of health care services by a case manager; and
(e) payor
efforts to identify treatment alternatives and modify benefit restrictions for
high-cost patient care.
(3) “Managed
health care bureau (MHCB)” means
the managed health care bureau within the office of superintendent of
insurance.
(4) “Maternity benefits” means covered benefits for prenatal, intrapartum,
perinatal or postpartum care.
(5) “Medical necessity” or “medically
necessary” means health care services determined by a provider, in
consultation with the health insurance carrier, to be appropriate or necessary,
according to:
(a) any applicable generally accepted principles and practices
of good medical care;
(b) practice guidelines developed by the federal government,
national or professional medical societies, boards and associations; or
(c) any applicable clinical protocols or practice guidelines
developed by the health insurance carrier consistent with such federal,
national and professional practice guidelines.
These standards shall be applied to decisions related to the diagnosis
or direct care and treatment of a physical or behavioral health condition,
illness, injury or disease.
(6) “Medical record” means all information maintained by a provider relating
to the past, present or future physical or behavioral health of a patient, and for other provision of health care services to
a patient. This information includes,
but is not limited to the provider’s notes, reports and summaries, and x-rays,
laboratory, and other diagnostic test results.
A patient’s complete medical record includes information generated and
maintained by the provider, as well as other information provided to the
provider by the patient, by any other provider who has consulted with or
treated the patient in connection with the provision of health care services to
the patient. A medical record does not
include the patient’s medical billing or health insurance records or forms or
communications related thereto.
(7) “Medicare” means Title 18 of the Social Security Amendments of
1965, “Health Insurance for Aged and
Disabled,” as then constituted or later amended.
(8) “Medicare supplement policy” means a group or individual policy of insurance or a subscriber
contract other than a policy issued pursuant to a contract under Section 1876
of the Social Security Act (42 U.S.C. Section 1395 et seq.) or an issued policy
under a demonstration project specified in 42 U.S.C. Section 1395ss(g)(1) that
is advertised, marketed or designed primarily as a supplement to reimbursements
under medicare for the hospital, medical or surgical
expenses of persons eligible for medicare; “medicare supplement policy” does not include medicare advantage plans established under medicare part C, outpatient prescription drug plans
established under medicare part D or any health care
prepayment plan (HCPP) that provides benefits pursuant to an agreement under 42
U.S.C. Section 1833(a)(1)(A) of the Social Security Act.
N. Terms beginning with the letter “N”:
(1) “Network” means the group or groups of participating providers who
provide health care services under a network plan.
(2) “Network plan” means a health benefits plan that either requires a
covered person to use, or creates incentives, including financial incentives,
for a covered person to use health care providers and facilities managed, owned
or under contract with or employed by the health insurance carrier.
(3) “Nonparticipating provider” means a provider who is not a participating provider as
defined in Paragraph (1) of Subsection P of this section. Also known as an
out-of-network provider or non-contracted provider.
O. Terms beginning with the letter “O”: “Obstetrician-gynecologist” means a
physician who is eligible to be or who is board certified by the American board
of obstetricians and gynecologists or by the American college of osteopathic
obstetricians and gynecologists.
P. Terms beginning with the letter “P”:
(1) “Participating provider” means a provider who, under an express contract with a
health insurance carrier or with its contractor or subcontractor, has agreed to
provide health care services to covered persons with an expectation of
receiving payment directly or indirectly from the carrier, subject to any
cost-sharing required by the health benefits plan. Also known as an in-network provider or
contracted provider.
(2) “Physician assistant (PA)” means a skilled person who is a graduate of a physician
assistant or surgeon assistant program approved by a nationally recognized
accreditation body or who is currently certified by the national commission on
certification of physical assistants, and who is licensed to practice medicine,
usually under the supervision of a licensed physician.
(3) “Post-service claim” means a claim submitted to a health insurance carrier by
or on behalf of a covered person after health care services have been provided
to the covered person.
(4) “Practitioner of the healing arts”
means a health care professional as defined in Paragraph (2) of Subsection B of
Section 59A-22-32 NMSA 1978.
(5) “Preventive care” means health care services provided for prevention and
early detection of disease, illness, injury or other health condition.
(6) “Primary care” means health care services for a range of common
physical or behavioral health conditions provided by a physician or
non-physician primary care practitioner.
(7) “Primary care practitioner (PCP)” means a health care professional who, within the scope
of the professional license, supervises, coordinates and provides initial and
basic care to covered persons; who initiates the patient’s referral for
specialist care and who maintains continuity of patient care. Primary care practitioners include general
practitioners, family practice physicians, geriatricians, internists,
pediatricians, obstetrician-gynecologists, physician assistants and nurse
practitioners. Pursuant to 13.10.21.7
NMAC, other health care professionals may also serve as primary care
practitioners.
(8) “Prior authorization” or “pre-certification”
means a pre-service determination made by a health insurance carrier regarding
a covered person’s eligibility for health care services based on medical
necessity, health benefits coverage and the appropriateness and site of
services pursuant to the terms of the health benefits plan.
(9) “Private health insurance
cooperative” means a nonprofit corporation formed to
arrange for health benefits coverage with health insurance carriers for its
participating members, including large and small employers.
(10) “Product” means a discrete package of health insurance benefits
that is offered using a particular network type within a service area.
(11) “Prospective enrollee” means:
(a) in the case
of an individual who is a member of a group, an individual eligible for
enrollment in a health benefits plan through the group; or
(b) in the case of an individual who is not a member of a group
or whose group has not purchased or does not intend to purchase a health
benefits plan, an individual who has expressed an interest in purchasing
individual plan coverage.
(12) “Prospective
review” means
utilization review conducted prior to the provision of health care services by
the health insurance carrier.
(13) “Provider” means a licensed health care professional, hospital or
other facility authorized to furnish health care services.
(14) “Provider
group”
means an incorporation or other legal association of
providers who work together in proximity and share resources for as well
liability that may result from the provision of patient care.
Q. Terms beginning with the letter “Q”:
(1) “Qualified
health plan (QHP)” means a major medical plan that has been reviewed and deemed
by the superintendent to provide essential health benefits, follow established
limits on cost-sharing, provide “minimum essential coverage” and meet the other
requirements of the Affordable Care Act.
(2) “Quality
assurance plan” means the ongoing, internal quality assurance program of a
health insurance carrier to monitor and evaluate the carrier’s health care
services, including its system for credentialing health care professionals to
become participating providers with a health benefits plan or otherwise provide
services to the carrier’s covered persons.
R. Terms beginning with “R”:
(1) “Reduction” means any provision that reduces the amount
of a benefit; a risk of loss is assumed but payment upon the occurrence of the
loss is limited to some amount or period less than otherwise would be payable
and the reduction has not been used.
(2) “Registered lay midwife” means any person who
practices lay midwifery and is registered as a lay
midwife by the New Mexico department of health.
(3) “Retrospective review” means utilization review that is conducted
following the provision of health care services.
S. Terms
beginning with the letter “S”:
(1) “Second opinion” means an opportunity or requirement for a covered person
to obtain a clinical evaluation to assess the medical necessity and
appropriateness of the initial proposed health service, by a provider other
than one who originally recommended or denied it.
(2) “Short-term,
limited-duration plan” or “short-term plan” means a
nonrenewable major medical plan with a specified duration of not more than
three months that is issued only to individuals who have not been enrolled in a
plan providing the same or similar nonrenewable coverage from any carrier
within the past twelve months and which so states in all advertisements,
marketing materials and application and policy forms.
(3) “Specialist” means a physician or
non-physician health care professional who:
(a) focuses on a specific area of physical or behavioral health
or a specific group of patients; and
(b) has successfully completed required training and is
recognized by the state in which the health care professional practices to
provide specialty care.
(4) “Specialty
care”
means advanced, medically necessary care and treatment by a specialist,
preferably in coordination with a primary care practitioner or other health
care professional, of specific physical or behavioral health conditions or
health conditions that may manifest in a particular age group or other
subpopulation.
(5) “Stabilize” means to provide physical or behavioral health treatment
of a condition as may be necessary to ensure, within a reasonable medical
probability, that no material deterioration of the condition is likely to
result from or occur during the transfer of the individual to or from a
facility or, with respect to an emergency birth with no complications resulting
in a continuing emergency, to deliver the child and the placenta.
(6) “Subscriber” means an individual whose employment or other status, except
family dependency, is the basis for eligibility for enrollment in the health
benefits plan, or in the case of an individual contract, the person in whose
name the contract is issued.
(7) “Summary of benefits” means a summary of the benefits and exclusions required
to be given prior to or at the time of enrollment to a prospective subscriber
or covered person by the health insurance carrier.
(8) “Superintendent”
means the superintendent of insurance, the office of superintendent of
insurance (OSI), or employees of OSI acting with the superintendent’s
authorization.
T. Terms beginning with the letter “T”:
(1) “Telemedicine” or “Telehealth”
means the use by a health care professional of interactive, simultaneous audio and
video or store-and-forward technology using information and telecommunications
technologies to deliver health care services at a site other than the site
where the patient is located, including the use of electronic media for
consultation relating to the diagnosis or treatment of the patient in real time
or through the use of store-and-forward technology.
(2) “Tertiary care facility” means a hospital unit that provides complete perinatal
care and intensive care of intrapartum and perinatal high-risk patients with
responsibilities for coordination of transport, communication, education and
data analysis systems for the geographic area served.
(3) “Third-party
administrator (TPA)” is as defined in Subsection B of Section 59A-12A-2
NMSA 1978.
(4) “Tiered network” means a network that supports a health benefits plan in
which there are at least two quantitatively different cost-sharing levels for
participating providers who or which furnish the same covered services.
(5) “Traditional fee-for-service indemnity
benefit” means a fee-for-service indemnity benefit as
defined in Subsection LL of 13.10.17.7 NMAC, as a fee-for-service indemnity
benefit, not associated with any financial incentives that encourage covered
persons to utilize preferred providers, to follow pre-authorization rules, to
utilize prescription drug formularies or other cost-saving procedures to obtain
prescription drugs, or to otherwise comply with a plan’s incentive program to
lower cost and improve quality, regardless of whether the benefit is based on
an indemnity form of reimbursement for services.
U. Terms beginning with the letter “U”:
(1) “Urgent care situation” means
a situation in which a prudent layperson in that circumstance,
possessing an average knowledge of medicine and health would believe that he or she does not have an
emergency medical condition but needs care expeditiously because:
(a) the life or health of the covered person would otherwise be
jeopardized;
(b) the covered person’s ability to regain maximum function
would otherwise be jeopardized;
(c) in the opinion of a physician with knowledge of the covered
person’s medical condition, delay would subject the covered person to severe
pain that cannot be adequately managed without care or treatment;
(d) the medical
exigencies of the case require expedited care; or
(e) the covered person’s claim otherwise involves urgent care.
(2) “Utilization
review” means a system for reviewing the appropriate and efficient
allocation of health care services given or proposed to be given to a patient
or group of patients.
V. Terms beginning with the letter “V”: [RESERVED]
W. Terms beginning with the letter “W”: [RESERVED]
X. Terms beginning with the letter “X”: [RESERVED]
Y. Terms beginning with the letter “Y”: [RESERVED]
Z. Terms beginning with the letter “Z”: [RESERVED]
[13.10.29.7 NMAC - N, 10/01/2018; A, 2/12/2019]
HISTORY OF 13.10.29 NMAC: [RESERVED]