New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 35 - Minimum Standards for Dental and Vision Plans
Section 13.10.35.10 - DENTAL PLANS
Universal Citation: 13 NM Admin Code 13.10.35.10
Current through Register Vol. 35, No. 18, September 24, 2024
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.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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