Current through Register Vol. 35, No. 18, September 24, 2024
A. Any
private health insurance cooperative operating in New Mexico shall register
with the agent licensing bureau of the insurance division of the New Mexico
public regulation commission prior to commencing operations.
B. All business entities should be aware that
other licensing and registration requirements for corporations and partnerships
may exist. Corporations may contact the corporations bureau of the New Mexico
public regulation commission at (505) 827-4387 to determine the applicable
requirements and to register. Partnerships may contact the secretary of state's
office (505) 827-3600 to determine the applicable requirements and to
register.
C. The registration
process with the agent licensing bureau of the insurance division shall include
verification that the private health insurance cooperative:
(1) has provided:
(a) name;
(b) New Mexico public regulation commission
corporations number;
(c) New Mexico
address as registered;
(d) New
Mexico city of registration;
(e)
state and zip code of registration;
(f) sufficient evidence that the entity is in
good standing with the secretary of state (if the date is not identical to the
current date, then the agent licensing bureau shall notify the private health
insurance cooperative that it may not negotiate contracts until its good
standing is re-established);
(g)
member-employer names, addresses, cities of registration, states, zip codes,
and New Mexico tax I.D. numbers; and
(h) the private health insurance
cooperative's employee names and addresses;
(2) has not been formed by, nor has as a
member, a carrier, pursuant to the prohibition in Chapter 59A, Article 23 NMSA
1978;
(3) has established
procedures under which an applicant for or participant in its group health
benefit plan coverage may have a grievance reviewed by an impartial entity,
specifically by requiring the carrier to electronically file a
non-grandfathered grievance plan with the New Mexico public regulation
commission, insurance division, managed health care bureau that shall be
subject to and comply with the insurance division's grievance procedures rule
pertaining to internal and external grievance review (13.10.17 NMAC);
(4) has developed and implemented a plan to
maintain public awareness of the private health insurance cooperative and
publicize the eligibility requirements for, and the procedures for enrollment
in, its group health benefit plan coverage;
(5) in instances wherein the private health
insurance cooperative has made available to its members more than one group
health benefit plan, has made each group health benefit available to all
employees covered by the cooperative;
(6) ensures that any group health benefit
plan provided through the private health insurance cooperative provides
coverage for diabetes equipment, supplies and services;
(7) does not self-insure or self-fund any
health benefit plan or portion of a plan; and
(8) has contracted only with a carrier that
demonstrates that it:
(a) is in good standing
with the division;
(b) has the
capacity to administer health benefit plans;
(c) is able to monitor and evaluate the
quality and cost-effectiveness of care and applicable procedures;
(d) is able to conduct utilization management
and establish applicable procedures and policies;
(e) is able to ensure that enrollees have
adequate access to health care providers, including adequate numbers and types
of providers;
(f) has a
satisfactory grievance procedure that is subject to and shall comply with the
insurance division's grievance procedures rule (13.10.17 NMAC) and is able to
respond to enrollees' calls, questions and complaints; and
(g) has financial capacity, either through
satisfying solvency standards that the superintendent shall set or through
appropriate reinsurance or other risk-sharing mechanisms.
