Current through Register Vol. 35, No. 18, September 24, 2024
A. A
MHCP shall not cancel the coverage of an enrollee except for "good cause,"
which, for the purposes of this section means:
(1) failure of the enrollee or subscriber to
pay the premiums and other applicable charges for coverage;
(2) material failure to abide by the rules,
and/or policies and procedures of the MHCP;
(3) fraud or material misrepresentation
affecting coverage;
(4) a reason
for cancellation or failure to renew which the superintendent determines is not
objectionable.
B.
Notwithstanding Subsection A of 13.10.23.8 NMAC, a MHCP shall not cancel an
enrollee's coverage for non-payment of copayments if such a cancellation would
constitute abandonment of a covered person who is hospitalized and is receiving
treatment for a life threatening condition. In addition, a MHCP shall not
cancel an enrollee's coverage due to a covered person's refusal to follow a
prescribed course of treatment.
C.
Before an enrollee's coverage may be terminated by the MHCP, the MHCP must
provide written notice of at least 30 calendar days to the enrollee.
Notification of cancellation of enrollment must:
(1) be in writing and dated;
(2) state the reason(s) for cancellation,
with specific reference to the clause of the MHCP contract giving rise to the
right of cancellation;
(3) state
that an enrollee cannot be canceled because of health status, need for health
care services, race, gender, age, or sexual orientation of covered persons
under enrollee's contract;
(4)
state that an enrollee who alleges that an enrollment has been canceled or not
renewed because of the enrollee's or covered person's health status, need for
health care services, race, gender, age, or sexual orientation may request
review of the cancellation by the superintendent as set forth in 13.10.17
NMAC;
(5) state that in the event
of cancellation by either the enrollee or MHCP, except in the case of fraud or
deception in the use of services or facilities of the MHCP or knowingly
permitting such fraud or deception by another, the MHCP shall, within 30
calendar days, return to the enrollee or subscriber the pro rata portion of the
money paid to the MHCP which corresponds to any unexpired period for which
payment had been received together with amounts due on claims, if any, less any
amounts due the MHCP; provided, however, that the superintendent may approve
other reasonable reimbursement practices;
(6) state the date on which the cancellation
becomes effective;
(7) state that
receipt by the MHCP of the proper prepaid or periodic payment, including all
past due amounts, after cancellation of the contract for nonpayment shall
reinstate the contract as though it had never been canceled if such payment is
received on or before the due date of the succeeding prepaid or periodic
payment; provided, however, that the contract may specify one or more of the
following methods by which the MHCP may avoid such reinstatement:
(a) in the notice of cancellation, the MHCP
notifies the enrollee that if payment is not received within 15 days of
issuance of the notice of cancellation, a new application is required and the
conditions under which a new contract will be issued or whether the original
contract will be reinstated;
(b) if
such payment is received more than 15 calendar days after issuance of the
notice of cancellation, the MHCP refunds the payment within 20 business days;
or
(c) if such payment is received
more than 15 calendar days after issuance of the notice of cancellation, the
MHCP issues to the enrollee, within 20 business days of receipt of such
payment, a new contract accompanied by a written notice clearly stating the
ways in which the new contract differs from the canceled contract, including
any difference in benefits or coverage;
(8) state that the MHCP is prohibited from
increasing the amount paid by the enrollee, except after a period of at least
30 calendar days from either:
1) the postage
paid mailing to the enrollee at the enrollee's address of record with the MHCP;
or
2) actual hand delivery to the
enrollee of written notice of such proposed increase; and
(9) state that the MHCP is prohibited from
decreasing the benefits stated in the contract in any manner, except after a
period of at least 30 calendar days from either:
1) the postage paid mailing to the enrollee
at the enrollee's address of record with the MHCP; or
2) actual hand delivery to the enrollee of
written notice of such proposed change(s).
D. In the event that the MHCP cancels or
refuses to renew a managed health care plan contract, or enrollment under the
contract, the MHCP shall mail a notice of the cancellation to the enrollee at
the enrollee's address of record with the MHCP. However, in the event that the
MHCP cancels or refuses to renew a group contract, the MHCP need not mail a
notice of cancellation to each enrollee covered by the group plan if:
(1) the plan contract requires the group
contract holder to mail promptly any such notice to each enrollee;
(2) the MHCP mails or hand delivers a notice
of cancellation to the group contract holder designated in the plan contract,
and the MHCP gives a written reminder to the group contract holder of its
obligation under the contract; and
(3) the MHCP demonstrates that the group
contract holder promptly provided proof to the MHCP of the mailing of a legible
true copy of the notice of cancellation to each enrollee at the enrollee's
current address and the date the mailing occurred.
E. Each MHCP contract shall provide a notice
of cancellation, pursuant to Paragraph (3) of Subsection C of 13.10.23.8 NMAC
and will not be effective any sooner than 30 calendar days after the notice is
mailed to the enrollee.
F. The
terms "cancellation" and "failure to renew," for the purposes of this section
do not include a voluntary termination by an enrollee or the termination of a
plan or contract which does not contain a renewal provision.
