New Mexico Register / Volume XXXII,
Issue 11 /June 8, 2021
TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 35 MINIMUM STANDARDS FOR DENTAL AND
VISION PLANS
13.10.35.1 ISSUING AGENCY: Office of
Superintendent of Insurance (“OSI”).
[13.10.35.1
NMAC - N, 01/01/2022]
13.10.35.2 SCOPE: This rule
applies to every carrier who offers or sells any individual or group dental or
vision insurance plan (“plan”) separately from a health benefits plan. This rule does not apply to any pediatric dental or vision plan, or to any prepaid dental plan. Subject
to the foregoing, this rule applies to a group dental or vision plan offered or sold to a New Mexico
resident under a master policy delivered outside of this
state.
[13.10.35.2 NMAC - N, 01/01/2022]
13.10.35.3 STATUTORY AUTHORITY: Sections
59A-2-9 and 59A-23G-1 et seq. NMSA 1978.
[13.10.35.3
NMAC - N, 01/01/2022]
13.10.35.4 DURATION: Permanent.
[13.10.35.4
NMAC - N, 01/01/2022]
13.10.35.5 EFFECTIVE DATE: January 1, 2022 unless
a later date is cited at the end of a section. If the superintendent previously
approved a subject plan, that plan shall comply with this rule no later than January
1, 2022, if issued on or after that date.
[13.10.35.5
NMAC - N, 01/01/2022]
13.10.35.6 OBJECTIVE: Establish
minimum regulatory standards and sales practices relating to dental and vision
plans; standardize and simplify the terms and coverages; facilitate
public understanding and comparison of coverage; eliminate provisions that may
be misleading or confusing in connection with the purchase and renewal of
the coverages or with the settlement of claims; and require disclosures in the
marketing and sale of the subject plans.
[13.10.35.6
NMAC - N, 01/01/2022]
13.10.35.7 DEFINITIONS: For definitions of terms contained in this rule, refer to
13.10.29 NMAC, unless otherwise noted below.
A. “Domestic co-insured” means a spouse or domestic
partner insured under the same plan or certificate.
B. “Preferred
provider” means a dental or vision care
provider, or group of providers, who contracts with a dental or vision insurance carrier to provide
dental or
vision services to a
covered person.
[13.10.35.7
NMAC - N, 01/01/2022]
13.10.35.8 GENERAL PROHIBITED POLICY
PROVISIONS:
A. Probationary and waiting periods. Except as
otherwise expressly allowed under Sections 10 and 11 of this rule, a plan shall not include any probationary or waiting period during
which no coverage is provided for a covered benefit, except an eligibility waiting period during
which no premium is paid.
B. Riders and other
supplements. Any rider, amendment, endorsement or other supplement shall
explicitly state which terms
of coverage the carrier has amended or supplemented
from the original plan.
C. Exclusions. A plan that includes a preexisting condition exclusion shall comply with these requirements:
(1) each
plan application shall include a prominent notice that the plan includes a
preexisting exclusion, and display either the full text of the exclusion or directions
as to how to obtain a copy of that text.
(2) the
carrier shall not enforce a preexisting condition exclusion if an enrollee
renews coverage under a plan offered by the same carrier.
(3) a
plan application shall not request family member health information unless the
family member is also seeking coverage under the plan; and
(4) a
plan may exclude benefits for the replacement
of a tooth that the covered person lost prior to the covered person’s plan
effective date, unless the covered person had coverage from a prior carrier.
D. Evidence of
coverage. Upon request, a carrier shall provide a current or former enrollee
evidence of that
person’s current or former coverage under a plan.
E. Marketing of blanket or group coverages. A carrier
shall not sell any blanket coverage to a group that is not described in Section
59A-23-2 NMSA 1978, or group coverage that is not identified or described in
Section 59A-23-3 NMSA 1978.
F. Arbitration provisions. A plan shall not
require a covered person to submit a dispute to mediation or arbitration.
G. Plan governance. A covered person’s
rights under any plan shall be governed by the terms of the plan approved by
the superintendent, and by applicable state and federal law.
H. Discrimination. No plan shall
discriminate in eligibility for coverage or benefits on the basis of sex,
sexual orientation, gender, race, religion, or national origin
I. Conversion privileges. A carrier shall not offer a
conversion plan that is not approved by the superintendent.
J. Gag rule. A
plan shall not include, and a carrier shall not otherwise impose, a gag rule or
practice that prohibits a dental or vision service provider from discussing a
treatment option with a covered person.
[13.10.35.8
NMAC - N, 01/01/2022]
13.10.35.9 GENERAL STANDARDS FOR POLICIES AND
BENEFITS:
A. For individual plans. The following general standards
apply to individual plans.
(1) An
individual plan shall have a minimum term of 12 months.
(2) A
“noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed
renewable” individual plan shall not provide for termination of coverage of the
domestic co-insured solely because of the occurrence of an event specified for
termination of coverage of the covered person, other than nonpayment of
premium. In addition, the plan shall provide that in the event of the covered
person’s death, the domestic co-insured of the covered person, if covered under
the plan, shall become a covered person with the issuance of a new policy and
completed agreement.
(3) An
individual plan shall protect consumer rights as follows:
(a) The terms “noncancellable” or “noncancellable and guaranteed
renewable” may only be used in an individual dental or vision plan if the
covered person has the right to continue the coverage by timely paying
premiums, until the age of 65 or until eligibility for Medicare, whichever is
later, during which time the carrier has no unilateral right to change any
provision of the plan.
(b) The term “guaranteed renewable” may only be used in a plan
where the covered person has the right to continue in force, by timely paying premiums,
until the age of 65 or until eligibility for Medicare, whichever is later,
during which period the carrier has no unilateral right to change any provision
of the plan, other than changes in premium rates by classes.
(c) A plan shall
not terminate the coverage of a covered person except for “good cause,” as
follows:
(i) failure of the
covered person or subscriber to pay the premiums and other applicable charges
for coverage;
(ii) material
failure to abide by the rules, policies or procedures of the plan;
(iii) fraud or
misrepresentation affecting coverage;
(iv) policyholder
request for cancellation;
(v) policy term
ends; or
(vi) a reason for termination or failure to renew that the
superintendent determines is not objectionable.
(4) If an individual plan covers
domestic co-insureds, the age of the younger insured shall be used as the basis
for meeting the age and durational requirements of the definitions of
“noncancellable” or “guaranteed renewable.” However, this requirement shall not
prevent termination of coverage of the older insured upon attainment of the
stated age so long as the policy may be continued in force as to the younger
spouse to the age or for the durational period specified in the policy.
B. For individual and group plans. The following
general standards apply to both individual and group plans.
(1) A
carrier may not terminate a plan unless it provides written notice of
termination to a covered person one month prior to the coverage renewal date. A
notice of termination shall:
(a) be
in writing and dated;
(b) state
the reason(s) for termination, with specific references to the clauses of the
dental or vision plan giving rise to the termination;
(c) state
that a covered person’s plan cannot be terminated because of health status,
need for services, race, gender, or sexual
orientation of covered persons under the contract.
Age may only be a factor in termination of coverage as outlined in Paragraph (4)
of Subsection A and Paragraph (7) of Subsection B of this section;
(d) state
that a covered person who alleges that an enrollment has been terminated or not
renewed because of the covered person’s health status, need for health care
services, race, gender, age or sexual orientation may file a complaint with the
superintendent of by phone or on the Office
of Superintendent of Insurance website; and
(e) state
that in the event of termination by either the covered person or the plan,
except in the case of fraud or deception, the plan shall, within 30 calendar
days, return to the covered person or subscriber the pro rata portion of the
money paid to the plan that corresponds to any unexpired period for which
payment had been received together with amounts due on claims, if any, less any
amounts due to the plan, provided, however, that the superintendent may approve
other reasonable reimbursement practices.
(2) A
plan shall include a notice prominently printed on or attached to the first
page of the plan stating that the covered person shall have the right to return
the plan within 30 days of its delivery, and to have the premium and any
required membership fees refunded, if after examination of the plan the covered
person is not satisfied for any reason, provided no claim has been paid.
(3) If
a plan includes a conversion privilege, the provision shall be captioned,
“Conversion Privilege.” The provision shall specify who is eligible for
conversion and the circumstances that govern conversion, or may state that the
conversion coverage will be provided as an approved plan form used by the
carrier for that purpose.
(4) If
a carrier requires submission of a claim form as a condition of payment, the
carrier, upon receipt of notice of a claim, shall furnish to the covered person
a form to be delivered in the manner offered by the carrier that is preferred
by the covered person. If the carrier does not furnish a claim form within 15
days after notice of a claim, the claimant shall be deemed to have complied
with the requirement to provide proof of loss if the notice of claim contains
written proof describing the claim, including the character and extent of the
loss of which the claim is made. Adequate proof of loss must be in the
possession of the insurance company at the time funds are disbursed in payment
of claims.
(5) A grace period of at least 10
days for a monthly premium plan and at least 31 days for any plan billed less
frequently shall be granted for the payment of each premium falling due after
the first premium. During this grace period, the plan shall continue in force.
(6) A carrier shall not use any
untrue statement or inducement not specified in a policy to solicit a
prospective plan enrollee.
(a) A statement shall be deemed untrue if
it does not conform to fact in any respect and would be considered significant
to a person contemplating enrollment with a plan.
(b) Inducements shall meet the requirements of Subsections G and H of
Section 59A-16-17 NMSA 1978.
(7) A plan may
terminate the coverage of a dependent due to limiting age for a dependent per the plan’s
contracted age limits. However, a plan must offer coverage to dependents,
regardless of age, who are physically or mentally disabled prior to reaching
the limiting age and are incapable of self-sustaining employment. Coverage for
a child who is physically or mentally disabled prior to reaching the limiting
age and incapable of self-sustaining employment on the date the child would
otherwise age out of coverage shall continue if the child depends on the
covered person for support and maintenance. The plan may require that within 31
days of the date the company receives proof of the child’s incapacity, the
covered person may elect to continue the plan in force with respect to the
child.
C. For group coverage.
A group plan shall comply with Sections 8, 9, 11, and 12 of 13.10.5 NMAC, and Subsection
D of 13.10.5.10 NMAC.
[13.10.35.9
NMAC - N, 01/01/2022]
13.10.35.10 DENTAL
PLANS:
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 or 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 a
waiting period of no longer than six consecutive months:
(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.
(5) Craniomandibular
and temporomandibular joint disorders. A dental plan sold in conjunction with a
qualified health plan shall cover the diagnosis and treatment of
craniomandibular and temporomandibular joint disorders, if such coverage is not
offered
by the qualified health plan.
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.
[13.10.35.10
NMAC - N, 01/01/2022]
13.10.35.11 VISION
PLANS:
A. Applicability. This section only applies
to subject vision plans.
B. Definitions. For purposes of this
section:
(1) “covered
materials” means materials that are reimbursable by a vision plan to a vision
care provider subject to any deductible, copayment, coinsurance, or other plan
limitation;
(2) “covered
services” means services that are reimbursable by a vision plan vision plan to
a vision care provider subject to any deductible, copayment, coinsurance, or
other plan limitation;
(3) “materials”
means ophthalmic devices, including;
(a) lenses;
(b) frames;
(c) contact
lenses; and
(d) spectacle
or contact lens treatments and coatings;
(4) “noncovered
materials” means materials that are not covered by a vision plan;
(5) “noncovered
services” means services that are not covered by a vision plan.
(6) “vision
services” means services provided by a vision care provider;
(7) “vision
plan” is a policy, contract, agreement or arrangement under which an entity
undertakes to reimburse claims for the cost of vision services or vision
materials; and
(8) “vision
care provider” means an individual licensed under state law as an optometrist or ophthalmologist.
C. Required minimum benefits.
A vision plan shall provide each covered person benefits for the following vision
services and vision materials. A pediatric vision plan sold in conjunction with
a qualified health plan shall provide vision coverage mandated by law for the
qualified health plan, or the benefits mandated by this rule, whichever are
most favorable to the member.
(1) Examinations.
At least once every consecutive two-year period for adults and once every 12-month
consecutive period for children under the age of 19, a comprehensive vision
examination. The comprehensive vision examination shall include a complete
analysis of the eyes and related structures, as appropriate, to determine the
presence of vision problems or other abnormalities.
(2) Lenses.
If the vision examination indicates that corrective lenses are necessary, each
covered person is entitled to necessary frames and lenses, including coverage
for single vision, bifocal, trifocal, and lenticular as medically necessary and up to the stated benefit limit of the plan. This
benefit may be limited to once each two-year consecutive period, unless medical
necessity requires increased frequency, and may be subject to a maximum one
month waiting period.
(3) Contact
lenses shall be covered as follows:
(a) Medically
necessary contact lenses shall be covered in full, up to a benefit maximum,
subject to prior authorization from the vision plan if dispensed or provided by
an in-network provider or vendor.
(b) A
vision plan shall provide an elective contact lens allowance up to the stated benefit
limit of the plan.
(c) This
benefit may be limited to once each 12-month consecutive period, and may be
subject to a maximum one month waiting period.
D. Noncovered services
and materials. A vision plan may exclude coverage for the following
services and materials:
(1) any
that are not medically necessary;
(2) any
that were not obtained in compliance with the requirements of the vision plan;
(3) any
medical or surgical treatment of the eyes;
(4) vision
therapy; and
(5) two
pairs of glasses in lieu of bifocals.
[13.10.35.11
NMAC - N, 01/01/2022]
13.10.35.12 COORDINATION
AND COMBINATION OF BENEFITS:
A. A dental or vision plan shall only
coordinate or combine benefits as permitted under state or federal law and
as specified in the plan.
B. A carrier and
plan that offers both dental and vision benefits is subject to both the dental
and vision provisions of this rule.
[13.10.35.12
NMAC - N, 01/01/2022]
13.10.35.13 COVERAGE DOCUMENTATION:
A. Coverage forms and
benefits disclosures.
(1) A carrier shall issue a policy, certificate of coverage or summary of
benefits to each covered person on or
before the effective date of coverage or of a
change in coverage. Covered groups may distribute a certificate of coverage or summary of benefits on behalf
of the carrier.
(2) The
policy, certificate of coverage or summary
of benefits shall include a clear and complete statement of:
(a) the
covered services, supplies and materials;
(b) any
limitations or exclusions including any charge, deductible or copayment
feature;
(c) where
and in what manner information is available as to how services may be obtained;
(d) a
clear and understandable description of the method for resolving a covered
person’s complaint.
(e) conditions
for renewal and reinstatement;
(f) procedures
for filing claims;
(g) a
statement of the amounts payable to the carrier by a covered person and the times at
which the amounts shall be paid;
(h) the period during which the plan
is effective; and
(i) on
the front page, the identity of the carrier.
(3) Any
subsequent change in coverage or premium shall be explained in a separate
document delivered to the covered person.
B. Notice required.
The following language shall be provided in a summary of benefits:
READ
YOUR PLAN CAREFULLY - THIS BENEFITS SUMMARY PROVIDES A VERY BRIEF DESCRIPTION
OF THE IMPORTANT FEATURES OF YOUR PLAN. THIS IS NOT THE INSURANCE CONTRACT. YOUR
FULL RIGHTS AND BENEFITS ARE EXPRESSED IN THE ACTUAL PLAN DOCUMENTS THAT ARE
AVAILABLE TO YOU UPON YOUR REQUEST TO US.
C. Contact information. The policy, certificate or summary of benefits shall state the
plan’s contact information and the website and phone number of the office of superintendent
of insurance.
[13.10.35.13
NMAC - N, 01/01/2022]
13.10.35.14 NETWORK ADEQUACY: Each dental or
vision plan that in any way conditions coverage on the
provision of services by a preferred provider shall
maintain an adequate network of such providers:
A. Attestation. A carrier shall submit to the superintendent annually
an attestation of compliance with all of the criteria of this section by
October 1, 2022 and every year thereafter.
(1) That,
in population areas of 50,000 or more residents, two dental or vision care
providers are available in any county within no more than 20 miles or 20 minutes’
average driving time for ninety percent of the enrolled population, or, in
population areas of less than 50,000, whether two dental or vision care
providers are available in any county or service area within no more than 60 miles or 60 minutes’
average driving time for ninety percent of the enrolled population. For remote
rural areas, the superintendent shall consider on a case by case basis whether
the dental or vision plan has made sufficient providers available given the
number of residents in the county or service area and given the community’s
standard of care.
(2) That
the dental or vision plan provides reasonable and reliable access for its
covered persons to qualified health care professionals in those specialties
that are covered by the dental or vision plan.
(3) Any
major deficiencies in the dental or vision plan’s provider network and a
description of current activities to remedy network deficiencies.
B. Provider lists.
A dental or vision carrier must
maintain a list on its website of all providers contracted with the plan.
(1) The
list shall be updated monthly and shall;
(a) include
specialty providers;
(b) identify
the providers who are not currently accepting new patients; and
(c) be
available to both covered persons and plan applicants.
(2) The
dental or vision plan shall audit its provider list for accuracy on an annual
basis.
C. Out of state
providers. A carrier is permitted to enter contracts or other arrangements with out of state
providers to meet the access requirements of this rule.
D. Provider
grievances. A dental or vision carrier shall
accept, investigate and resolve provider grievances about plan operations
pursuant to 13.10.16 NMAC.
E. Emergency care.
If a covered person receives emergency care for a covered dental or vision service specified
in this rule and cannot reach a preferred dental
or vision provider, as judged by the perspective of a
reasonable person in the same or similar circumstances or after prior
authorization, the plan shall reimburse the covered person as if the care was
provided in-network.
F. Preferred provider
arrangements. A dental or
vision carrier
that delivers services through a preferred provider arrangement shall comply
with the preferred provider arrangements law, Section 59A-22A-2 NMSA 1978.
[13.10.35.14
NMAC - N, 01/01/2022]
13.10.35.15 UTILIZATION MANAGEMENT DETERMINATIONS:
A. Denial of services. A benefit denial that is based
on a determination that a dental or vision service is not medically necessary,
and that is the result of a formal prior authorization review process, shall be
supported by a contemporaneous opinion of a provider licensed to provide the
requested service. Any such
determination shall be made in accordance with medical necessity standards and
appropriate clinical guidelines.
B. Pretreatment
Estimates. A carrier may issue a non-binding pretreatment estimate for the
coverage and reimbursement of proposed dental or vision services. A
pretreatment estimate does not determine medical necessity and does not serve
as a prior authorization.
(1) A
pretreatment estimate shall include a statement that clearly indicates to the
covered person that the estimate is not a guarantee of coverage.
(2) A
pretreatment estimate shall clearly identify the services that require an
approved prior authorization for coverage and shall include a statement that the
covered person may be liable for the full cost of the service if an approved
prior authorization is not obtained.
C. Timeliness of
determinations. A carrier shall make all prior authorization determinations as required by the exigencies of the situation and in
accordance with sound medical principles, and in no more than five business
days. If after five business days the carrier does not expect to be able to complete the determination due to
unforeseen circumstances or missing information, the carrier shall inform the covered person or
their provider of the circumstances or the information missing and the need to
extend the determination timeframe.
D. Post-authorization
denials. A carrier shall not deny any
claim subsequently submitted for procedures specifically included in an
approved prior authorization unless the
date of service is within 18 months and at least one of the
circumstances below applies for each denied procedure:
(1) benefit
limitations, such as annual maximums and frequency limitations not applicable
at the time of prior authorization are reached due to utilization subsequent to
the issuance of prior authorization;
(2) documentation
for the claim provided by the person submitting the claim clearly fails to
support the claim as originally authorized;
(3) if,
after the issuance of the prior authorization, new procedures are provided to
the patient or a change in the patient’s condition occurs such that the prior
authorized procedure would no longer be considered medically necessary based on
the prevailing standard of care;
(4) if,
after the issuance of the prior authorization, new care is rendered to the
patient or a change in the patient’s condition occurs such that the prior
authorized procedure would at that time require disapproval pursuant to the
terms and conditions for coverage under the patient’s plan in effect at the
time the prior authorization was issued;
(5) another
payer is responsible for the payment;
(6) another
payer has already paid the claim;
(7) the
claim was submitted fraudulently or the prior authorization was based on whole
or material part on erroneous information provided to the carrier by the provider, covered person or other person not related
to the carrier; or
(8) the
person receiving care was not eligible for covered benefits on the date of
service and the carrier did not know, and with the exercise of reasonable care
could not have known of the person’s eligibility status.
E. Notice of denial.
If a carrier denies a request for prior authorization, it shall deliver to the covered persons a written explanation
of the basis for the denial within 24 hours of the determination for emergency
care and within 10 calendar days for all other care.
[13.10.35.15 NMAC - N, 01/01/2022]
13.10.35.16 CONSUMER
COMPLAINTS: A carrier
shall state in all plan documents that a covered person who cannot
resolve a complaint with the plan may contact the office of the superintendent
of insurance.
[13.10.35.16
NMAC - N, 01/01/2022]
13.10.35.17 PENALTIES: In addition to
any applicable suspension, revocation or refusal to continue any certificate of
authority or license under the Insurance Code, a penalty for any material
violation of this rule may be imposed against a health care insurance carrier
by the superintendent in accordance with Sections 59A-1-18 and 59A-46-25 NMSA
1978.
[13.10.35.17
NMAC - N, 01/01/2022]
13.10.35.18 SEVERABILITY: If any section
of this rule, or the applicability of any section to any person or
circumstance, is for any reason held invalid by a court of competent
jurisdiction, the remainder of the rule, or the applicability of such
provisions to other persons or circumstances, shall not be affected.
[13.10.35.18
NMAC - N, 01/01/2022]
History of
13.10.35 NMAC: [RESERVED]