N.M. Admin. Code § 13.10.13.11

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.13.11 - COORDINATION OF BENEFITS

A. A health care insurer may or may not coordinate benefits in some or all of its group and individual managed health care plan contracts. However, a health care insurer which does coordinate benefits may do so only pursuant to the provisions in its plan contracts, all of which shall be fair, reasonable, and consistent with the objectives of this rule and shall comply with all applicable rules and regulations governing coordination of benefits.

B. A provision regarding coordination of benefits shall be presumed to be unfair and unreasonable if it:

(1) may relieve the health care insurer of a duty otherwise arising from a contract to deliver any health care service to any covered person in need of such service because the covered person may be or is entitled to coverage of the service by another health carrier; or

(2) results in any covered person who cooperates with such provision having greater personal liability for any particular health care service furnished by or through the health care insurer or received in reliance on the health care insurer than such person would have had in the absence of any other health carrier.

N.M. Admin. Code § 13.10.13.11

13.10.13.11 NMAC - Rp, 13.10.13.24 NMAC, 9/1/2009