N.M. Admin. Code § 13.10.26.8

Current through Register Vol. 35, No. 21, November 5, 2024

Section 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.

N.M. Admin. Code § 13.10.26.8

13.10.26.8 NMAC - N, 10-15-12