Current through Register Vol. 35, No. 18, September 24, 2024
A PBM shall not conduct any operation or provide any service
in New Mexico unless it holds a valid PBM license issued by the
superintendent.
A. A PBM shall apply
for a license by submitting a complete application package on a form, and
pursuant to the directions, prescribed by the superintendent. The application
package shall include:
(1) The non-refundable
filing fee prescribed by Paragraph (1) of Subsection AA of Section
59A-6-1 NMSA 1978
for filing an application for a license.
(2) The name of the legal entity, federal
employer identification number ("FEIN"), business address, phone number and
state of residency.
(3) The name,
business address, phone number and e-mail address of a contact person
designated by the PBM to respond to grievances.
(4) The name, business address, phone number
and e-mail address of a contact person designated by the PBM to respond to
inquiries by the superintendent.
(5) Proof of current authority from the
controlling New Mexico regulator to conduct business in New Mexico.
(6) For each partner, managing member, and
director, as applicable, the application package shall include a background
investigation report through a vendor approved by OSI upon initial application.
Changes in leadership shall submit a background investigation report at the
time of renewal of license.
(7) For
the preceding 10 years, a statement of whether the application has:
(a) been refused a registration, license or
certification to act as or provide the services of a PBM or third-party
administrator; or
(b) had any
registration, license or certification denied, suspended, revoked or
non-renewed for any reason by any state or federal entity; and
(c) if either (a) or (b) apply, the PBM shall
separately attach the details of each such action, including the date, nature
and disposition of the action.
(8) A statement of whether the applicant in
the most recent 10 years had a business relationship terminated for any
admission, legal finding, or judgement of fraudulent or illegal activities in
connection with the administration of a pharmacy benefits plan and a
description of each termination.
(9) A list of all New Mexico clients serviced
by the PBM.
(10) A list of each
regulatory enforcement action against the PBM in any other state for the
previous 10 years.
(11) The
application shall be shall be signed and verified by an officer, director,
managing member, or partner, as applicable, of the PBM.
(12) Any other information that is deemed
necessary by the superintendent in evaluating the application to evidence
compliance with Chapter 59A, Article 61 NMSA 1978 or the requirements of rules
promulgated by the superintendent.
(13) Confidentiality requests by an applicant
are governed by the superintendent's bulletin 2022-001 or any superseding
bulletin or rule.
(14) The
application package, except for the application fee, shall be submitted as
directed by the superintendent. After the application has been approved or
rejected by the PBM program coordinator, the applicant shall pay the
application fee through NIPR. Failure to pay the application fee for a rejected
application will preclude licensure or renewal.
B.
Review and approval process for
initial licensure. Within 30 days of receipt of an application pursuant
to Subsection A of this section, the superintendent will review the application
and:
(1) if the application is incomplete,
notify the applicant in writing that additional information is needed, and
allow the applicant 30 days to cure any deficiency in the
application.
(2) approve the
application and issue a PBM license to the applicant if the superintendent
determines that the applicant meets the requirements for licensure;
or
(3) deny the application if the
superintendent determines that the applicant does not meet the requirements for
licensure.
C.
Content and scope of license.
(1)
Content. A license issued by the superintendent
under this rule shall identify the PBM by name and business address; the
capacity of the licensee to act as a PBM in New Mexico; and the effective and
expiration dates of the license.
(2)
Scope. A license issued under this regulation entitles the PBM to
act for one or more authorized insurance carriers, health plans, workers'
compensation insurers, Medicaid MCO, multiple employer welfare arrangement or
government plan or persons that self-insure without being required to obtain a
separate license.
D.
License renewal. To continue a license a PBM shall submit a
renewal application by March 1, of each year pursuant as directed by the
superintendent After the application has been approved or rejected by the PBM
program coordinator, the applicant shall pay the required application fee
through NIPR and shall pay the annual report fee as directed by the
superintendent. Failure to pay the application fee will preclude renewal. A
renewal application shall include updates to any items required by the initial
application for licensure.
E.
Review and approval process for renewal of license. Within 60 days
of receipt of a renewal license application, the superintendent will review the
application and:
(1) if the application is
incomplete, notify the applicant in writing that additional information is
needed, and allow the applicant 30 days to cure any deficiency in the
application.
(2) approve the
application and issue a PBM license to the applicant if the superintendent
determines that the application meets the requirements for licensure;
or
(3) deny the application if the
superintendent determines that the applicant does not meet the requirements for
licensure. For disapprovals or denials of an application for renewal the
superintendent will notify the applicant of the denial or rejection and state
the basis or reason for the denial.
F.
Corrective action plan. In
lieu of a denial for initial licensure or renewal, the superintendent may
require the PBM to submit a plan to cure or correct deficiencies in its
application.
