N.M. Code R. § 13.10.9.9 – Policy or Plan Criteria; Minimum Requirements

A. Mandatory provisions: Policies or plans issued pursuant to the Minimum Healthcare Protection Act shall meet the criteria set forth in Section 59A-23B-3B NMSA 1978 regarding eligibility, managed care provisions and minimum healthcare services to covered individuals.
B. Optional provisions: Policies or plans issued pursuant to the Minimum Healthcare Protection Act may include the managed care and cost control features provided in Section 59A-23B-3C NMSA 1978 regarding panels of healthcare service providers, second opinions before elective surgery, utilization review and a maximum limit on the cost of healthcare services covered in any calendar year of not less than $50,000. Pursuant to Section 59A-23B-3D NMSA 1978 a policy or plan may include additional managed care and cost control provisions that the superintendent of insurance determines to have the potential for controlling costs in a manner that does not cause discriminatory treatment of individuals, families or groups covered by the policy or plan.
C. Pre-existing conditions: Pursuant to Section 59A-23B-3E NMSA 1978, notwithstanding any other provisions of law, a policy or plan shall not exclude coverage for losses incurred for a pre-existing condition more than six months from the effective date of coverage. The policy or plan shall not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment recommended by or received from a physician within six months before the effective date of coverage.
D. Home healthcare coverage:
(1) For purposes of the Minimum Healthcare Protection Act and this rule, home healthcare coverage offered shall include:
(a) services provided by a registered nurse or a licensed practical nurse;
(b) health services provided by physical, occupational and respiratory therapists and speech pathologists;
(c) health services provided by a home health aide; and
(d) medical supplies, drugs and medicines and laboratory services, to the extent they would have been covered if provided to the insured on an inpatient basis.
(2) Home healthcare coverage may be limited to:
(a) services provided on the written order of a licensed physician, provided such order is renewed at least every sixty (60) days;
(b) services provided, directly or through contractual agreements, by a home health agency licensed in the state in which the home health services are delivered; and
(c) services, as set forth in 13 NMAC 10.9.9.4.1 [now Paragraph (1) of Subsection D of 13.10.9.9 NMAC], without which the insured would have to be hospitalized.
(3) A day of home healthcare shall consist of up to four (4) continuous hours of home healthcare services. Home healthcare services provided in hourly increments of less than four (4) hours shall be calculated in proportion to the relationship which the hours of service provided bear to a four (4) hour day, e.g., two (2) hours of home healthcare constitute one-half (½) day of home healthcare, etc.
(4) Provided, however, that home healthcare coverage, alone or in combination with inpatient hospitalization coverage, shall not exceed twenty five (25) days pursuant to the provisions of Section 59A-23B-3B(3)(a) NMSA 1978.
E. Usual, customary and reasonable charges:
(1) For purposes of a policy or plan issued pursuant to the Minimum Healthcare Protection Act and this rule, a usual, customary and reasonable charge shall be the lesser of:
(a) the customary charge which would be made by the healthcare services provider for the same service or medical supplies in the absence of insurance;
(b) the general level of charge for a comparable service or medical supplies made by other healthcare service providers in the same geographic area; or
(c) the actual charge made by the healthcare services provider.
(2) This provision does not apply to charges of providers who are paid under contractual arrangements at specified levels of reimbursement as permitted by Section 59A-23B-3C NMSA 1978.
F. Enrollment waiting period: A policy or plan issued pursuant to this rule which does not exclude coverage for pre-existing conditions as permitted by this rule may impose, in lieu of such exclusion, a six-month waiting period for enrollment of members of a group who have pre-existing medical conditions on the effective date of the group’s coverage.
[5/1/92; Recompiled 11/30/01]