TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 26 REGISTRATION
OF PRIVATE HEALTH INSURANCE COOPERATIVES
13.10.26.1 ISSUING
AGENCY:
New Mexico Public Regulation Commission,
Insurance Division.
[13.10.26.1
NMAC - N, 10-15-12]
13.10.26.2 SCOPE: This rule applies to private health insurance
cooperatives established under Chapter 59A, Article 23 NMSA 1978.
[13.10.26.2
NMAC - N, 10-15-12]
13.10.26.3
STATUTORY AUTHORITY: Sections 59A-2-9 and 59A-23-3 NMSA 1978.
[13.10.26.3
NMAC - N, 10-15-12]
13.10.26.4 DURATION: Permanent.
[13.10.26.4
NMAC - N, 10-15-12]
13.10.26.5 EFFECTIVE
DATE:
October 15, 2012, unless a later date is
cited at the end of a section.
[13.10.26.5
NMAC - N, 10-15-12]
13.10.26.6 OBJECTIVE: To establish minimum registration requirements
for private health insurance cooperatives.
[13.10.26.6
NMAC - N, 10-15-12]
13.10.26.7 DEFINITIONS:
A. "Private health insurance
cooperative" means a nonprofit corporation formed to arrange for
health benefit plan coverage with insurance carriers for its participating
member large or small employers.
B. "Carrier" means carrier as
defined in Section 59A-23-11.Q (1) NMSA 1978.
C. "Large employer" means a
large employer as defined in Section 59A-23-11.Q (2) NMSA 1978.
D. "Small employer" means a small
employer as defined in as defined in Section 59A-23-11.Q (3) NMSA 1978.
[13.10.26.7
NMAC - N, 10-15-12]
13.10.26.8 REGISTRATION
REQUIREMENTS:
A. Any private
health insurance cooperative operating in New Mexico shall register with the agent
licensing bureau of the insurance division of the New Mexico public regulation commission
prior to commencing operations.
B. All business entities should be aware that
other licensing and registration requirements for corporations and partnerships
may exist. Corporations may contact the corporations bureau
of the New Mexico public regulation commission at (505) 827-4387 to determine
the applicable requirements and to register.
Partnerships may contact the secretary of state’s office (505) 827-3600
to determine the applicable requirements and to register.
C. The registration
process with the agent licensing bureau of the insurance division shall include
verification that the private health insurance cooperative:
(1)
has provided:
(a) name;
(b)
New Mexico public regulation commission
corporations number;
(c) New
Mexico address as registered;
(d) New Mexico city of registration;
(e) state and zip code
of registration;
(f) sufficient evidence that the entity is in good
standing with the secretary of state (if the date is not identical to the
current date, then the agent licensing bureau shall notify the private health
insurance cooperative that it may not negotiate contracts until its good
standing is re-established);
(g) member-employer names, addresses, cities
of registration, states, zip codes, and
New Mexico tax I.D. numbers; and
(h) the private health
insurance cooperative’s employee names and addresses;
(2) has
not been formed by, nor has as a member, a carrier, pursuant to the prohibition
in Chapter 59A, Article 23 NMSA 1978;
(3) has established
procedures under which an applicant for or participant in its group health
benefit plan coverage may have a grievance reviewed by an impartial entity,
specifically by requiring the carrier to electronically file a
non-grandfathered grievance plan with the New Mexico public regulation commission,
insurance division, managed health care bureau that shall be subject to and
comply with the insurance division’s grievance procedures rule pertaining to
internal and external grievance review (13.10.17 NMAC);
(4) has
developed and implemented a plan to maintain public awareness of the private
health insurance cooperative and publicize the eligibility requirements for,
and the procedures for enrollment in, its group health benefit plan coverage;
(5) in instances wherein
the private health insurance cooperative has made available to its members more
than one group health benefit plan, has made each group health benefit
available to all employees covered by the cooperative;
(6) ensures
that any group health benefit plan provided through the private health
insurance cooperative provides coverage for diabetes equipment, supplies and
services;
(7) does
not self-insure or self-fund any health benefit plan or portion of a plan; and
(8) has
contracted only with a carrier that demonstrates that it:
(a)
is in good standing with the division;
(b) has the capacity to administer health
benefit plans;
(c) is able to monitor and evaluate the
quality and cost-effectiveness of care and applicable procedures;
(d) is able to conduct utilization management
and establish applicable procedures and policies;
(e) is able to ensure that enrollees have
adequate access to health care providers, including adequate numbers and types
of providers;
(f)
has a satisfactory grievance procedure that is subject to and shall
comply with the insurance division’s grievance procedures rule (13.10.17 NMAC)
and is able to respond to enrollees’ calls, questions and complaints; and
(g)
has financial capacity, either through
satisfying solvency standards that the superintendent shall set or through appropriate
reinsurance or other risk-sharing mechanisms.
[13.10.26.8
NMAC - N, 10-15-12]
13.10.26.9 ANNUAL REQUIRED FILING:
A. Each private
health insurance cooperative shall file an annual report for the preceding
calendar year with the superintendent on or before March 1 of each year, or
within such extension of time as the superintendent for good cause may grant.
The report shall be in the form and contain such matters as the superintendent
prescribes and shall be verified by at least two officers or two partners of
the private health insurance cooperative.
B. The annual
report shall include the complete names and addresses of all insurers with
which the private health insurance cooperative had an agreement during the
preceding fiscal year. If requested in writing by the private health insurance
cooperative, the names and addresses of the insureds may be kept confidential
by the superintendent.
[13.10.26.9
NMAC - N, 10-15-12]
HISTORY OF
13.10.26 NMAC:
[RESERVED]