Current through Register Vol. 35, No. 18, September 24, 2024
A.
Evidence of coverage: At the time of enrollment, each managed
health care plan (MHCP) shall provide each covered person with information on
how to access and obtain an evidence of coverage. Upon request at any time
after enrollment, the covered person shall be provided with the evidence of
coverage. Each evidence of coverage offered to covered persons, and prospective
covered persons shall state in clear, accurate, and conspicuous language, in
not less than 10 point font, written such that it can be easily understood by
the average covered person, and so that it comports with the requirements of
the "Policy Language Simplification Law," Chapter 59A, Article 19 NMSA 1978,
the following information:
(1) the name of
the health care insurer and managed health care plan and its principal place of
business, including its address and telephone number;
(2) definitions for words that have meanings
other than common general usage;
(3) for an HMO, a description of the HMO's
service area;
(4) a complete list
or description of the comprehensive basic health care services, urgent health
care services, emergency health care services, and, if applicable, supplemental
health care services available within the MHCP's service or geographical area,
and any other benefits to which the covered person is entitled under the
particular plan;
(5) an explanation
of how participation in the managed health care plan may affect the potential
covered person's choice of physician, hospital, or other health care
provider;
(6) eligibility
requirements for coverage, including a statement of conditions on eligibility
for benefits;
(7) conditions of
cancellation, which shall include a statement that if a covered person believes
coverage was canceled due to health status or health care requirements, race,
gender, age, or sexual orientation, he may appeal termination to the
superintendent;
(8) the name,
address, and toll-free telephone number of the superintendent;
(9) a statement that a copy of the evidence
of coverage will be provided upon request if the covered person is unable to
obtain a copy of the contract from the covered person's employer or other
contract holder;
(10) conditions
for renewal and reinstatement;
(11)
any procedures for filing claims;
(12) in bold typeface, or through an equally
or more effective means, highlight any and all exclusions or limitations on the
health care services, type of health care services, benefits, or type of
benefits to be provided, including deductibles or copayments, or co-insurance;
when presented on the plan's website or through other internet means, this
information may be highlighted with movement, color, pop-up material, and other
devices;
(13) any other
requirements or procedures necessary for covered persons to obtain particular
health care services, such as additional copayments, prior authorizations,
second opinions, and consultations with or referrals to specialists,
physicians, or other providers other than the primary care physician;
(14) the covered person's personal financial
obligation for non-covered health care services;
(15) a clear and complete summary of where,
and in what manner, information is available regarding how a covered person
obtains services, including emergency and out-of-area services;
(16) a toll-free telephone number and a
web-based or other electronic methods through which the covered person may
contact the MHCP for additional information on obtaining health care services
or for other inquiries regarding the plan, including benefit information and
plan requirements;
(17) for all
contracts, a list of relevant copayments and all other out of pocket expenses
paid by the covered person;
(18)
for individual and conversion contracts, the contractual periodic prepayment or
premium, which may be contained in a separate insert and the total of payment
for health services and the indemnity or services benefits, if any, which the
covered person is obligated to pay;
(19) a description of the MHCP's grievance
procedures and method for resolving covered person complaints, including a
description of the appeals process available if the MHCP limits or excludes
coverage of a treatment or procedure, the address and telephone number to which
grievances are to be directed, and a statement identifying the superintendent
as an external source with whom grievances may be filed, including the division
of insurance contact information, as provided at Paragraph (2) of Subsection A
of 13.10.17.24 NMAC, so that the covered person may submit the
complaint;
(20) if the MHCP
provides prescription drug coverage, the evidence of coverage must convey in
clear and concise language:
(a) whether
participating providers are restricted to prescribing drugs from a drug
formulary;
(b) whether or not
brand-name products or specialty drugs require a higher copayment;
(c) the extent, if at all, to which an
enrollee will be reimbursed for costs of a drug that is not on the plan's
formulary;
(d) how covered persons
may obtain, upon request, a complete list of drugs covered by the plan or
listed on the MHCP's drug formulary; and
(e) any exclusions or limitations for
coverage of "experimental," "investigational," or "specialty" drugs and
definitions of "experimental," "investigational," and "specialty" as those
terms are used by the MHCP, and in accordance with this chapter;
(21) a list of providers which
contains all of the information listed in Subsection D of 13.10.22.8 NMAC, and
shall include a statement, if applicable, that providers may be deleted or
added within the coverage year;
(22) a statement regarding whether or not
participating providers must comply with any specified numbers, targeted
averages, or maximum durations of patient visits; and if so, a description of
the specific requirements;
(23) a
statement reflecting that a covered person will not be liable to a provider for
any sums owed to the provider by the MHCP;
(24) language reflecting that the enrollee
may be liable for sums owed to a non-contracting provider, except when an
enrollee or covered person is mistakenly referred to a non-participating
provider by a MHCP provider as discussed in Subsection C of 13.10.22.8 NMAC;
and
(25) a statement explaining the
covered person's rights and responsibilities as required by 13.10.13.8
NMAC.
B.
Toll-free number: The toll-free telephone number referred to in
Paragraph (16) of Subsection A of this section shall:
(1) be answered twenty-four (24) hours a day,
seven days a week, so that covered persons who need assistance may obtain
answers to their questions;
(2) be
equipped so that covered persons with non-medical benefit information questions
may leave a voice-mail message for the MHCP that the administrative office of
the MHCP will answer before 5:00 p.m. on the next business day;
(3) be included on a covered person
membership card issued by the MHCP.
G.
Termination of provider status:
(1)
When an HMO terminates or suspends any contract with a participating provider,
the HMO shall notify, in writing, affected covered persons who are current
patients of or, where applicable, assigned to the provider, within 30 days. The
notice to covered persons shall advise them of their right to continue
receiving care from the provider as set forth in 13.10.23.13 NMAC. Current
patients are covered persons who have a claim with the HMO related to the
provider's services within the past year, or who have received a
pre-authorization prior to termination to use the provider's services at a
future time.
(2) The HMO shall
assist such affected covered persons in locating and transferring to another
similarly qualified provider.
(3) A
covered person may not be held financially liable for services received from
the provider in good faith between the effective date of the suspension or
termination and the receipt of notice provided to the covered person, if the
covered person has not received comparable notice during this time from the
provider.
