N.M. Code R. § 13.10.2.12 – Nonprofit Health Plan Contracts

A. All subscriber contracts of a nonprofit health care plan delivered or issued for delivery in this state and which provide maternity coverage shall also provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section for a mother and her newly born child in a health facility unless earlier discharge is made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, including, but not limited to, the criterion that family members or other support person(s) should be available to the mother for the first few days following discharge. In addition, a decision for early discharge should be individualized and should be a mutual decision between the mother and the attending physician. Inpatient care in excess of a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a caesarian section for a mother and her newly born child in a health facility shall be covered if determined to be medically necessary by the attending physician.
B. Notwithstanding the provisions of sub-section 12.1 of this section [now Subsection A of 13.10.2.12 NMAC], a subscriber contract of a nonprofit health care plan delivered or issued for delivery in this state that provides coverage for postpartum care for a mother and her newly born child in the home shall not be required to provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarian section, unless such inpatient care is determined to be medically necessary by the attending physician, or early discharge is inconsistent with the most current version of the “Guidelines for Perinatal Care” prepared by the American academy of pediatrics and the American college of obstetricians and gynecologists, or this rule.
C. Postpartum care in the home shall be made in accordance with accepted maternal and neonatal physician assessments, by a person with appropriate licensure, training and experience to provide postpartum care. Services provided by such person shall include, but not be limited to, parent education, assistance and training in breast and bottle feeding, and the performance of any necessary and appropriate clinical tests.
D. Postpartum care in the home shall consist of a minimum of three home visits, unless one or two home visits are determined to be sufficient by the attending physician or person with appropriate licensure, training and experience to provide postpartum care, and the mother. The home visits shall be conducted within the time period ordered by the attending physician or person with appropriate licensure, training and experience to provide postpartum care.
E. Each nonprofit health care plan which provides maternity coverage in this state shall mail a written description of the coverage required under this rule, in a form approved by the superintendent, to the expectant mother covered by the nonprofit health care plan and to her attending physician, upon receipt by the nonprofit health care plan of notification of the diagnosis of pregnancy of the expectant mother.
F. In addition to the notification provided in subsection 12.5 [now Subsection E of 13.10.2.12 NMAC], each nonprofit health care plan which provides maternity coverage in this state shall mail a written statement, in a form approved by the superintendent, to the expectant mother covered by the nonprofit health care plan, notifying the expectant mother of her right to complain to the superintendent if there is concern that the mother or her newly born child has not received the coverage required by this rule. In the event of a complaint, the nonprofit health care plan will have the burden of proof to demonstrate that the coverage provided was in compliance with this rule.
[3/1/96; Recompiled 11/30/01]