TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 35 MINIMUM STANDARDS FOR DENTAL AND
VISION PLANS
13.10.35.1 ISSUING AGENCY: Office of
Superintendent of Insurance (“OSI”).
[13.10.35.1
NMAC - N, 01/01/2022]
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]
13.10.35.4 DURATION: Permanent.
[13.10.35.4
NMAC - N, 01/01/2022]
13.10.35.5 EFFECTIVE DATE: January 1, 2022, unless
a later date is cited at the end of a section. If the superintendent previously
approved a subject plan, that plan shall comply with this rule no later than
January 1, 2022, if issued on or after that date.
[13.10.35.5
NMAC - N, 01/01/2022]
13.10.35.6 OBJECTIVE: Establish
minimum regulatory standards and sales practices relating to dental and vision
plans; standardize and simplify the terms and coverages; facilitate
public understanding and comparison of coverage; eliminate provisions that may
be misleading or confusing in connection with the purchase and renewal of
the coverages or with the settlement of claims and require disclosures in the
marketing and sale of the subject plans.
[13.10.35.6
NMAC - N, 01/01/2022]
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. “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 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 (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 by
phone or on the 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) 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 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 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.
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.
(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.
(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]
13.10.35.12 COORDINATION
AND COMBINATION OF BENEFITS:
A. A dental or vision plan shall only
coordinate or combine benefits as permitted under state or federal law and
as specified in the plan.
B. A carrier and
plan that offers both dental and vision benefits is subject to both the dental
and vision provisions of this rule.
[13.10.35.12
NMAC - N, 01/01/2022]
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.
(2) The
policy, certificate of coverage or 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) cost-sharing
features must be written from the perspective of the insured;
(d) where and in what
manner information is available and as to how services may be obtained;
(e) a
clear and understandable description of the method for resolving a covered
person’s complaint;
(f) 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
clear and understandable description of the conditions for renewal;
(h) procedures for
filing claims;
(i) 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
following language shall be provided 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.
C. Contact information. The policy,
certificate and schedule of
benefits, if issued separately, shall
state the plan’s contact information and the website and phone number 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]
13.10.35.14 NETWORK ADEQUACY: Each dental or
vision plan that in any way conditions coverage on the
provision of services by a preferred provider shall
maintain an adequate network of such providers:
A. Attestation. A carrier shall submit to the superintendent
annually an attestation of compliance with all of the criteria of this section
by October 1, 2022 and every year thereafter.
(1) That,
in population areas of 50,000 or more residents, two dental or vision care
providers are available in any county within no more than 20 miles or 20 minutes’
average driving time for ninety percent of the enrolled population, or, in
population areas of less than 50,000, whether two dental or vision care
providers are available in any county or service area within no more than 60 miles or 60 minutes’
average driving time for ninety percent of the enrolled population. For remote
rural areas, the superintendent shall consider on a case by case basis whether
the dental or vision plan has made sufficient providers available given the
number of residents in the county or service area and given the community’s
standard of care.
(2) That
the dental or vision plan provides reasonable and reliable access for its
covered persons to qualified health care professionals in those specialties
that are covered by the dental or vision plan.
(3) Any
major deficiencies in the dental or vision plan’s provider network and a
description of current activities to remedy network deficiencies.
B. Provider lists.
A dental or vision carrier must
maintain a list on its website of all providers contracted with the plan.
(1) The
list shall be updated monthly and shall;
(a) include
specialty providers;
(b) identify
the providers who are not currently accepting new patients; and
(c) be
available to both covered persons and plan applicants.
(2) The
dental or vision plan shall audit its provider list for accuracy on an annual
basis.
C. Out of state
providers. A carrier is permitted to enter contracts or other arrangements with out of state
providers to meet the access requirements of this rule.
D. Provider
grievances. A dental or vision carrier shall
accept, investigate and resolve provider grievances
about plan operations pursuant to 13.10.16 NMAC.
E. Emergency care.
If a covered person receives emergency care for a covered dental or vision service specified
in this rule and cannot reach a preferred dental
or vision provider, as judged by the perspective of a
reasonable person in the same or similar circumstances or after prior
authorization, the plan shall reimburse the covered person as if the care was
provided in-network.
F. Preferred provider
arrangements. A dental or
vision carrier
that delivers services through a preferred provider arrangement shall comply
with the preferred provider arrangements law, Section 59A-22A-2 NMSA 1978.
[13.10.35.14
NMAC - N, 01/01/2022]
13.10.35.15 UTILIZATION MANAGEMENT DETERMINATIONS:
A. Denial of services. A benefit denial that is based
on a determination that a dental or vision service is not medically necessary,
and that is the result of a formal prior authorization review process, shall be
supported by a contemporaneous opinion of a provider licensed to provide the
requested service. Any such
determination shall be made in accordance with medical necessity standards and
appropriate clinical guidelines.
B. Pretreatment
Estimates. A carrier may issue a non-binding pretreatment estimate for the
coverage and reimbursement of proposed dental or vision services. A
pretreatment estimate does not determine medical necessity and does not serve
as a prior authorization.
(1) A
pretreatment estimate shall include a statement that clearly indicates to the
covered person that the estimate is not a guarantee of coverage.
(2) A
pretreatment estimate shall clearly identify the services that require an
approved prior authorization for coverage and shall include a statement that
the covered person may be liable for the full cost of the service if an
approved prior authorization is not obtained.
C. Timeliness of
determinations. A carrier shall make all prior authorization determinations as required by the exigencies of the situation and in
accordance with sound medical principles, and in no more than five business
days. If after five business days the carrier does not expect to be able to complete the determination due to
unforeseen circumstances or missing information, the carrier shall inform the covered person or their
provider of the circumstances or the information missing and the need to extend
the determination timeframe.
D. Post-authorization
denials. A carrier shall not deny any
claim subsequently submitted for procedures specifically included in an
approved prior authorization unless the
date of service is within 18 months and at least one of the
circumstances below applies for each denied procedure:
(1) benefit
limitations, such as annual maximums and frequency limitations not applicable
at the time of prior authorization are reached due to utilization subsequent to the issuance of prior authorization;
(2) documentation
for the claim provided by the person submitting the claim clearly fails to
support the claim as originally authorized;
(3) if,
after the issuance of the prior authorization, new procedures are provided to
the patient or a change in the patient’s condition occurs such that the prior
authorized procedure would no longer be considered medically necessary based on
the prevailing standard of care;
(4) if,
after the issuance of the prior authorization, new care is rendered to the
patient or a change in the patient’s condition occurs such that the prior
authorized procedure would at that time require disapproval pursuant to the
terms and conditions for coverage under the patient’s plan in effect at the
time the prior authorization was issued;
(5) another
payer is responsible for the payment;
(6) another
payer has already paid the claim;
(7) the
claim was submitted fraudulently or the prior
authorization was based on whole or material part on erroneous information
provided to the carrier by the provider, covered person or
other person not related to the carrier; or
(8) the
person receiving care was not eligible for covered benefits on the date of
service and the carrier did not know, and with the exercise of reasonable care
could not have known of the person’s eligibility status.
E. Notice of denial.
If a carrier denies a request for prior authorization, it shall deliver to the covered persons a written
explanation of the basis for the denial within 24 hours of the determination
for emergency care and within 10 calendar days for all other care.
[13.10.35.15 NMAC - N, 01/01/2022]
13.10.35.16 CONSUMER
COMPLAINTS: A carrier
shall state in all plan documents that a covered person who cannot
resolve a complaint with the plan may contact the office of the superintendent
of insurance.
[13.10.35.16
NMAC - N, 01/01/2022]
13.10.35.17 PENALTIES: In addition to
any applicable suspension, revocation or refusal to
continue any certificate of authority or license under the Insurance Code, a
penalty for any material violation of this rule may be imposed against a health
care insurance carrier by the superintendent in accordance with Sections
59A-1-18 and 59A-46-25 NMSA 1978.
[13.10.35.17
NMAC - N, 01/01/2022]
13.10.35.18 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 of competent
jurisdiction, the remainder of the rule, or the applicability of such
provisions to other persons or circumstances, shall not be affected.
[13.10.35.18
NMAC - N, 01/01/2022]
History of
13.10.35 NMAC: [RESERVED]