New Mexico Register / Volume XXIX,
Issue 18 / September 25, 2018
TITLE
13 INSURANCE
CHAPTER
10 HEALTH INSURANCE
PART
29 DEFINITIONS
13.10.29.1 ISSUING AGENCY: Office of Superintendent of Insurance (OSI),
Life and Health (L&H).
[13.10.29.1 NMAC - N, 10/01/2018]
13.10.29.2 SCOPE: This rule applies to all health insurance
carriers, including health maintenance organizations, individual health plans,
group and blanket health plans, provider service networks and nonprofit
healthcare plans that offer or administer health benefits plans, including
health benefits plans and managed health care plans subject to the insurance
laws and regulations of this state.
[13.10.29.2 NMAC - N, 10/01/2018]
13.10.29.3 STATUTORY AUTHORITY:
Sections 59A-2-8, 59A-2-9, 59A-7-3, 59A-18-2, 59A-18-13.2, 59A-18-13.3,
59A-18-16.2, 59A-22-1 et seq., 59A-23-2, 59A-23-3, and 59A-46-1 et seq. NMSA
1978.
[13.10.29.3 NMAC - N, 10/01/2018]
13.10.29.4 DURATION: Permanent.
[13.10.29.4 NMAC - N, 10/01/2018]
13.10.29.5 EFFECTIVE DATE: October 1, 2018, unless a later date is cited
at the end of a section.
[13.10.29.5 NMAC - N, 10/01/2018]
13.10.29.6 OBJECTIVE: The purpose of this rule is to
standardize the definitions utilized for rules applicable to health insurance
carriers as defined by the scope of this rule in 13.10.29.2 NMAC.
[13.10.29.6 NMAC - N, 10/01/2018]
13.10.29.7 DEFINITIONS:
A. Terms beginning with the letter “A”:
(1) “Accrued liability” means
liabilities established on the date an injury is sustained or an illness
commences.
(2) “Ambulance service”
means any transportation service designated and used or intended to be used for
the transportation of sick or injured persons.
(3) “Ambulatory surgical center”
means a facility where health care providers perform surgeries, including
diagnostic and preventive surgeries that do not require hospital admission.
(4) “Appointment waiting time”
means the time from the initial request for health care services by a covered
person or the covered person’s treating provider to the earliest date offered
for the appointment for services inclusive of the time for obtaining
authorization from the health insurance carrier or completing any other
condition or requirement of the carrier or its participating providers.
(5) “Authorized representative of a
covered person” means an individual selected and authorized in
writing by a covered person to represent the covered person’s interests in
matters related to the provision of services under a health benefits plan. Health care professionals and health
insurance agents and brokers may serve as authorized representatives of covered
persons.
(6) “Authorized representative of a
health insurance carrier” means an individual or organization
that is selected by the insurance company to represent its interests in an
aspect of the regulatory or hearing process.
B. Terms beginning with the letter “B”:
(1) “Behavioral health services” means
assessment, diagnosis, treatment or counseling in the context of a professional
relationship to assist an individual or group alleviate behavioral symptoms,
conditions or disorders, including mental health diagnoses and substance use
disorders, as well as other services to address developmental disability or
developmental delay.
(2) “Blanket health insurance” is a
form of health insurance covering special groups of not fewer than ten persons
that meets the criteria outlined in Section 59A-23-2 NMSA 1978.
(3) “Business day”
means a consecutive 24-hour period, excluding weekends or state holidays.
C. Terms beginning with the letter “C”:
(1) “Certificate” means
any certificate issued under an individual or group accident and health
insurance policy that has been delivered or issued for delivery in this state,
regardless of the state in which the policyholder is domiciled.
(2) “Certification
of service” means a determination by a health insurance carrier that a
health care service requested by a health care professional or covered person
has been reviewed and, based upon the information available, is a covered
benefit and meets the carrier’s requirements for medical necessity,
appropriateness, health care setting, level of care and effectiveness, and the
requested health care service is therefore approved. The certification of service can take place
following the health carrier’s utilization review process.
(3) “Certified
nurse-midwife” means any person who is licensed by the board of nursing as
a registered nurse and who is licensed by the New Mexico department of health
as a certified nurse-midwife.
(4) “Certified
nurse practitioner” means a registered nurse whose qualifications are
endorsed by the board of nursing for expanded practice as a certified nurse
practitioner and whose name and pertinent information are entered on the list
of certified nurse practitioners maintained by the board of nursing.
(5) “Claim”
means a request from a provider for payment for health care services rendered.
(6) “Clinical
peer” means a physician or other health care professional who holds a
similar non-restricted license in a state or territory of the United States and
in the same or similar specialty as typically manages the medical condition,
procedure, or treatment under review.
(7) “Clinical
review criteria” means the written screening procedures, decision
abstracts, clinical protocols and practice guidelines used by a health
insurance carrier to determine the medical necessity and appropriateness of
health care services.
(8) “Co-insurance”
is a cost-sharing method that requires a covered person to pay a stated
percentage of medical or pharmaceutical expenses after the deductible amount,
if any, is paid; co-insurance rates may differ for different types of services
under the same health benefits plan.
(9) “Copayment”
is a cost-sharing method that requires a covered person to pay a fixed dollar
amount when a medical or pharmaceutical service is received, with the health
insurance carrier paying the allowed balance; there may be different copayment
amounts for different types of services under the same health benefits plan.
(10) “Continuous
quality improvement” means ongoing and systematic efforts to measure,
evaluate, and improve a health insurance carrier’s processes and procedures in
order to continually improve the quality of health care services provided to
covered persons.
(11) “Cost-sharing”
means a copayment, co-insurance, deductible, or any other form of financial
obligation of a covered person other than premium or share of premium, or any
combination of any of these financial obligations as defined by the terms of
the health benefits plan.
(12) “Covered
benefits” means those health care services to which a covered person is
entitled under the terms of a health benefits plan.
(13) “Covered
person” or “enrollee” means a
subscriber, policyholder or subscriber’s enrolled dependent or dependents, or
other individual participating in a health benefits plan.
(14) “Credentialing”
means the process of obtaining, verifying and evaluating information about a
provider when the provider applies to become a participating provider within a
health insurance carrier’s network.
D. Terms beginning with
the letter “D”:
(1) “Day” or “Days” shall be interpreted as
follows, unless otherwise specified:
(a) one to five days means only
working days and excludes weekends and state holidays; and
(b) six or more days means calendar days, including weekends and
state holidays.
(2) “Deductible”
means a fixed dollar amount that a covered person may be required to pay
during a benefit period before the health insurance carrier begins payment for
covered benefits; health benefits plans may have both individual and family
deductibles and separate deductibles for specific services.
(3) “Designated
rating area” means a geographic unit designated by the superintendent and
used by insurers to determine health benefits plan premiums.
E. Terms beginning with
the letter “E”:
(1) “Emergency care”
means health care procedures, treatments or services delivered to a covered
person after the sudden onset of what reasonably appears to be a medical or
behavioral health condition that manifests itself by symptoms of sufficient
severity, including severe pain, that the absence of immediate medical
attention could be expected by a reasonable layperson to result in jeopardy to
a person’s physical or mental health or to the health or safety of a fetus or
pregnant person, serious impairment of bodily function, serious dysfunction of
a bodily organ or part or disfigurement to a person;
(2) “Enrollee”
or “covered person” means a subscriber, policyholder or subscriber’s enrolled dependent
or dependents, or other individual participating in a health benefits plan.
(3) “Essential
community provider (ECP)” means a provider as defined in 45 C.F.R.
§156.235(c).
(4) “Evidence
of coverage (EOC)” means a specific document containing a clear, conspicuous, concise and legible written statement of the
essential features and services covered by a health benefits plan given to the
covered person by the health insurance carrier or group contract holder, which
may include a separate summary of benefits as defined in Paragraph (6) of
Subsection S of this rule. The evidence
of coverage may serve as a covered person’s certificate as defined in Paragraph
(1) of Subsection C of this rule.
(5) “Exception”
or “exclusion” means any
provision in a health benefits plan whereby coverage for a specific hazard,
condition, or situation is excluded entirely.
It is a statement of a risk or risks not assumed by the health insurance
carrier under the plan.
F. Terms beginning with
the letter “F”:
(1) “Facility”
means an entity providing a health care service, including:
(a) a general, specialized, psychiatric or rehabilitation
hospital;
(b) an ambulatory surgical center;
(c) a cancer treatment center;
(d) a birth center;
(e) an inpatient, outpatient or residential drug and alcohol
treatment center;
(f) a laboratory, diagnostic or other outpatient medical
evaluation or testing center;
(g) a health care provider’s office or clinic;
(h) an urgent care center; or
(i) any other
therapeutic health care setting.
(2) “Federally
qualified health center (FQHC)” means an entity as defined in 42 C.F.R.
§405.2401.
(3) “FDA” means the United States food and
drug administration.
G. Terms beginning with
the letter “G”: “Group health insurance”
means a form of health insurance covering groups of persons, with or without
their dependents, and issued upon the criteria outlined in Section 59A-23-3
NMSA 1978.
H. Terms beginning with
the letter “H”:
(1) “Health benefits plan”
means a policy or agreement entered into, offered or issued by a health
insurance carrier to provide, deliver, arrange for, pay for or reimburse any of
the costs of health care services.
(2) “Health
care professional” means a physician or other health care practitioner,
including a pharmacist or practitioner of the healing arts, who is licensed, certified
or otherwise authorized by the state to provide health care services consistent
with state law.
(3) “Health
care service” means a service, supply or procedure for the diagnosis,
prevention, treatment, cure or relief of a health condition, illness, injury or
disease, including, to the extent covered by the health benefits plan, a
physical or behavioral health service.
(4) “Health
insurance carrier,” “health carrier,” “carrier”
or “health insurer” means an entity
subject to the insurance laws and regulations of this state, including a health
insurance company, a health maintenance organization, a hospital and health
services corporation, a provider service network, a non-profit health care plan
or any other entity that contracts or offers to contract, or enters into
agreements to provide, deliver, arrange for, pay for or reimburse any costs of
health care services, or that provides, offers health benefits plans or managed
health care plans in this state.
(5) “Health
maintenance organization (HMO)” is as defined in Subsection N of Section
59A-46-2 NMSA 1978.
(6) “Hospital”
means a facility offering inpatient services, nursing and overnight care for
three or more individuals on a 24-hour-per-day, seven-days-per-week basis for
the diagnosis and treatment of physical, behavioral or rehabilitative health
conditions.
I. Terms beginning
with the letter “I”: “Initial
determination” means a formal written disposition by a health insurance
carrier affecting a covered person’s rights to benefits, including full or
partial denial of a claim or request for coverage or its initial administrative
decision pursuant to the Grievance Procedures set forth at 13.10.17 NMAC.
J. Terms beginning
with the letter “J”: [RESERVED]
K. Terms beginning with the letter “K”:
[RESERVED]
L. Terms beginning with the letter
“L: “Limitation”
means any provision that restricts coverage under a health benefits plan other
than an exception, exclusion or reduction.
M. Terms beginning with
the letter “M”:
(1) “Managed care” means
a system or technique(s) generally used by third-party payors
or their agents to affect access to and control payment for health care
services. Managed care techniques most
often include one or more of the following:
(a) prior, concurrent and retrospective review of the medical
necessity and appropriateness of services or site of services;
(b) contracts with selected health care providers;
(c) financial incentives or disincentives for covered persons to
use specific providers, services, prescription drugs or service sites;
(d) controlled access to and coordination of health care
services by a case manager; and
(e) payor efforts to identify
treatment alternatives and modify benefit restrictions for high-cost patient
care.
(2) “Managed
health care bureau (MHCB)” means the managed health care bureau within the
office of superintendent of insurance.
(3) “Maternity
benefits” means covered benefits for prenatal, intrapartum, perinatal or
postpartum care.
(4) “Medical
necessity” or “medically necessary”
means health care services determined by a provider, in consultation with the
health insurance carrier, to be appropriate or necessary, according to:
(a) any applicable generally accepted principles and practices
of good medical care;
(b) practice guidelines developed by the federal government,
national or professional medical societies, boards and associations; or
(c) any applicable clinical protocols or practice guidelines
developed by the health insurance carrier consistent with such federal,
national and professional practice guidelines.
These standards shall be applied to decisions related to the diagnosis
or direct care and treatment of a physical or behavioral health condition,
illness, injury or disease.
(5) “Medical
record” means all information maintained by a provider relating to the
past, present or future physical or behavioral health of a patient,
and for other provision of health care services to a patient. This information includes, but is not limited
to the provider’s notes, reports and summaries, and x-rays, laboratory, and
other diagnostic test results. A
patient’s complete medical record includes information generated and maintained
by the provider, as well as other information provided to the provider by the patient,
by any other provider who has consulted with or treated the patient in
connection with the provision of health care services to the patient. A medical record does not include the
patient’s medical billing or health insurance records or forms or communications
related thereto.
(6) “Medicare”
means Title 18 of the Social Security Amendments of 1965, “Health Insurance for
Aged and Disabled,” as then constituted or later amended.
(7) “Medicare
supplement policy” means a group or individual policy of insurance or a
subscriber contract other than a policy issued pursuant to a contract under
Section 1876 of the Social Security Act (42 U.S.C. Section 1395 et seq.) or an
issued policy under a demonstration project specified in 42 U.S.C. Section
1395ss(g)(1) that is advertised, marketed or designed primarily as a supplement
to reimbursements under medicare for the hospital,
medical or surgical expenses of persons eligible for medicare;
“medicare supplement policy” does not include medicare advantage plans established under medicare part C, outpatient prescription drug plans
established under medicare part D or any health care
prepayment plan (HCPP) that provides benefits pursuant to an agreement under 42
U.S.C. Section 1833(a)(1)(A) of the Social Security Act.
N. Terms beginning with
the letter “N”:
(1) “Network” means the group
or groups of participating providers who provide health care services under a
network plan.
(2) “Network
plan” means a health benefits plan that either requires a covered person to
use, or creates incentives, including financial incentives, for a covered
person to use health care providers and facilities managed, owned or under
contract with or employed by the health insurance carrier.
(3) “Nonparticipating
provider” means a provider who is not a participating provider as defined
in Paragraph (1) of Subsection P of this rule.
Also known as an out-of-network provider or
non-contracted provider.
O. Terms beginning with
the letter “O”:
“Obstetrician-gynecologist” means a physician who is eligible to be
or who is board certified by the American board of obstetricians and
gynecologists or by the American college of osteopathic obstetricians and
gynecologists.
P. Terms beginning with
the letter “P”:
(1) “Participating provider”
means a provider who, under an express contract with a health insurance carrier
or with its contractor or subcontractor, has agreed to provide health care
services to covered persons with an expectation of receiving payment directly
or indirectly from the carrier, subject to any cost-sharing required by the
health benefits plan. Also known as an
in-network provider or contracted provider.
(2) “Physician
assistant (PA)” means a skilled person who is a graduate of a physician
assistant or surgeon assistant program approved by a nationally recognized
accreditation body or who is currently certified by the national commission on
certification of physical assistants, and who is licensed to practice medicine,
usually under the supervision of a licensed physician.
(3) “Post-service
claim” means a claim submitted to a health insurance carrier by or on
behalf of a covered person after health care services have been provided to the
covered person.
(4) “Practitioner of the healing arts”
means a health care professional as defined in Paragraph (2) of Subsection B of
Section 59A-22-32 NMSA 1978.
(5) “Preventive
care” means health care services provided for prevention and early
detection of disease, illness, injury or other health condition.
(6) “Primary
care” means health care services for a range of common physical or
behavioral health conditions provided by a physician or non-physician primary
care practitioner.
(7) “Primary
care practitioner (PCP)” means a health care professional who, within the
scope of the professional license, supervises, coordinates and provides initial
and basic care to covered persons; who initiates the patient’s referral for
specialist care and who maintains continuity of patient care. Primary care practitioners include general
practitioners, family practice physicians, geriatricians, internists,
pediatricians, obstetrician-gynecologists, physician assistants and nurse
practitioners. Pursuant to 13.10.21.7
NMAC, other health care professionals may also serve as primary care practitioners.
(8) “Prior
authorization” or “pre-certification”
means a pre-service determination made by a health insurance carrier regarding
a covered person’s eligibility for health care services based on medical
necessity, health benefits coverage and the appropriateness and site of
services pursuant to the terms of the health benefits plan.
(9) “Private
health insurance cooperative” means a nonprofit corporation formed to
arrange for health benefits coverage with health insurance carriers for its participating
members, including large and small employers.
(10) “Product”
means a discrete package of health insurance benefits that is offered using a
particular network type within a service area.
(11) “Prospective
enrollee” means:
(a) in
the case of an individual who is a member of a group, an individual eligible
for enrollment in a health benefits plan through the group; or
(b) in the case of an individual who is not a member of a group
or whose group has not purchased or does not intend to purchase a health
benefits plan, an individual who has expressed an interest in purchasing
individual plan coverage.
(12) “Prospective
review” means utilization review conducted
prior to the provision of health care services by the health insurance carrier.
(13) “Provider”
means a licensed health care professional, hospital or other facility
authorized to furnish health care services.
(14) “Provider
group” means an
incorporation or other legal association of providers who work together
in proximity and share resources for as well liability that may result from the
provision of patient care.
Q. Terms
beginning with the letter “Q”: “Quality
assurance plan” means the ongoing, internal quality assurance program of a
health insurance carrier to monitor and evaluate the carrier’s health care
services, including its system for credentialing health care professionals to
become participating providers with a health benefits plan or otherwise provide
services to the carrier’s covered persons.
R. Terms
beginning with “R”:
(1) “Reduction” means any provision that reduces
the amount of a benefit; a risk of loss is assumed but payment upon the
occurrence of the loss is limited to some amount or period less than otherwise
would be payable and the reduction has not been used.
(2) “Registered
lay midwife” means any
person who practices lay midwifery and is registered
as a lay midwife by the New Mexico department of health.
(3) “Retrospective
review” means utilization review that is
conducted following the provision of health care services.
S. Terms
beginning with the letter “S”:
(1) “Second opinion”
means an opportunity or requirement for a covered person to obtain a clinical
evaluation to assess the medical necessity and appropriateness of the initial
proposed health service, by a provider other than one who originally
recommended or denied it.
(2) “Specialist” means a physician or non-physician
health care professional who:
(a) focuses on a
specific area of physical or behavioral health or a specific group of patients;
and
(b) has successfully completed required training and is
recognized by the state in which the health care professional practices to
provide specialty care.
(3) “Specialty
care” means advanced, medically necessary
care and treatment by a specialist, preferably in coordination with a primary
care practitioner or other health care professional, of specific physical or
behavioral health conditions or health conditions that may manifest in a
particular age group or other subpopulation.
(4) “Stabilize”
means to provide physical or behavioral health treatment of a condition as may
be necessary to ensure, within a reasonable medical probability, that no
material deterioration of the condition is likely to result from or occur
during the transfer of the individual to or from a facility or, with respect to
an emergency birth with no complications resulting in a continuing emergency,
to deliver the child and the placenta.
(5) “Subscriber”
means an individual whose employment or other status, except family dependency,
is the basis for eligibility for enrollment in the health benefits plan, or in
the case of an individual contract, the person in whose name the contract is
issued.
(6) “Summary
of benefits” means a summary of the benefits and exclusions required to be
given prior to or at the time of enrollment to a prospective subscriber or
covered person by the health insurance carrier.
(7) “Superintendent”
means the superintendent of insurance, the office of superintendent of
insurance (OSI), or employees of OSI acting with the superintendent’s
authorization.
T. Terms beginning with
the letter “T”:
(1) “Telemedicine” or “Telehealth” means the use by a health
care professional of interactive, simultaneous audio and video or
store-and-forward technology using information and telecommunications
technologies to deliver health care services at a site other than the site
where the patient is located, including the use of electronic media for
consultation relating to the diagnosis or treatment of the patient in real time
or through the use of store-and-forward technology.
(2) “Tertiary
care facility” means a hospital unit that provides complete perinatal care
and intensive care of intrapartum and perinatal high-risk patients with
responsibilities for coordination of transport, communication, education and
data analysis systems for the geographic area served.
(3) “Third-party
administrator (TPA)” is as defined in Subsection B of Section 59A-12A-2
NMSA 1978.
(4) “Tiered
network” means a network that supports a health benefits plan in which
there are at least two quantitatively different cost-sharing levels for
participating providers who or which furnish the same covered services.
(5) “Traditional
fee-for-service indemnity benefit” means a fee-for-service indemnity
benefit as defined in Subsection LL of 13.10.17.7 NMAC, as a fee-for-service
indemnity benefit, not associated with any financial incentives that encourage
covered persons to utilize preferred providers, to follow pre-authorization
rules, to utilize prescription drug formularies or other cost-saving procedures
to obtain prescription drugs, or to otherwise comply with a plan’s incentive
program to lower cost and improve quality, regardless of whether the benefit is
based on an indemnity form of reimbursement for services.
U. Terms beginning with
the letter “U”:
(1) “Urgent care situation” means a situation in which a
prudent layperson in that circumstance, possessing an average knowledge of
medicine and health would believe that he or she does not have an emergency medical condition but
needs care expeditiously because:
(a) the life or
health of the covered person would otherwise be jeopardized;
(b) the covered person’s ability to regain maximum function
would otherwise be jeopardized;
(c) in the opinion of a physician with knowledge of the covered
person’s medical condition, delay would subject the covered person to severe
pain that cannot be adequately managed without care or treatment; or
(d) the medical exigencies of the case require expedited care;
and
(e) the covered person’s claim otherwise involves urgent care.
(2) “Utilization
review” means a system for reviewing the appropriate and efficient
allocation of health care services given or proposed to be given to a patient
or group of patients.
V. Terms beginning with the letter “V”: [RESERVED]
W. Terms beginning with the letter
“W”: [RESERVED]
X. Terms beginning with the letter
“X”: [RESERVED]
Y. Terms beginning with the letter
“Y”: [RESERVED]
Z. Terms beginning with the letter
“Z”: [RESERVED]
[13.10.29.7 NMAC - N, 10/01/2018]
HISTORY
OF 13.10.29 NMAC: [RESERVED]