N.M. Admin. Code § 13.10.30.8

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

Section 13.10.30.8 - REQUIREMENTS FOR LICENSURE

A PBM shall not conduct any operation or provide any service in New Mexico unless it holds a valid PBM license issued by the superintendent.

A. A PBM shall apply for a license by submitting a complete application package on a form, and pursuant to the directions, prescribed by the superintendent. The application package shall include:

(1) The non-refundable filing fee prescribed by Paragraph (1) of Subsection AA of Section 59A-6-1 NMSA 1978 for filing an application for a license.

(2) The name of the legal entity, federal employer identification number ("FEIN"), business address, phone number and state of residency.

(3) The name, business address, phone number and e-mail address of a contact person designated by the PBM to respond to grievances.

(4) The name, business address, phone number and e-mail address of a contact person designated by the PBM to respond to inquiries by the superintendent.

(5) Proof of current authority from the controlling New Mexico regulator to conduct business in New Mexico.

(6) For each partner, managing member, and director, as applicable, the application package shall include a background investigation report through a vendor approved by OSI upon initial application. Changes in leadership shall submit a background investigation report at the time of renewal of license.

(7) For the preceding 10 years, a statement of whether the application has:

(a) been refused a registration, license or certification to act as or provide the services of a PBM or third-party administrator; or

(b) had any registration, license or certification denied, suspended, revoked or non-renewed for any reason by any state or federal entity; and

(c) if either (a) or (b) apply, the PBM shall separately attach the details of each such action, including the date, nature and disposition of the action.

(8) A statement of whether the applicant in the most recent 10 years had a business relationship terminated for any admission, legal finding, or judgement of fraudulent or illegal activities in connection with the administration of a pharmacy benefits plan and a description of each termination.

(9) A list of all New Mexico clients serviced by the PBM.

(10) A list of each regulatory enforcement action against the PBM in any other state for the previous 10 years.

(11) The application shall be shall be signed and verified by an officer, director, managing member, or partner, as applicable, of the PBM.

(12) Any other information that is deemed necessary by the superintendent in evaluating the application to evidence compliance with Chapter 59A, Article 61 NMSA 1978 or the requirements of rules promulgated by the superintendent.

(13) Confidentiality requests by an applicant are governed by the superintendent's bulletin 2022-001 or any superseding bulletin or rule.

(14) The application package, except for the application fee, shall be submitted as directed by the superintendent. After the application has been approved or rejected by the PBM program coordinator, the applicant shall pay the application fee through NIPR. Failure to pay the application fee for a rejected application will preclude licensure or renewal.

B.Review and approval process for initial licensure. Within 30 days of receipt of an application pursuant to Subsection A of this section, the superintendent will review the application and:

(1) if the application is incomplete, notify the applicant in writing that additional information is needed, and allow the applicant 30 days to cure any deficiency in the application.

(2) approve the application and issue a PBM license to the applicant if the superintendent determines that the applicant meets the requirements for licensure; or

(3) deny the application if the superintendent determines that the applicant does not meet the requirements for licensure.

C.Content and scope of license.

(1)Content. A license issued by the superintendent under this rule shall identify the PBM by name and business address; the capacity of the licensee to act as a PBM in New Mexico; and the effective and expiration dates of the license.

(2)Scope. A license issued under this regulation entitles the PBM to act for one or more authorized insurance carriers, health plans, workers' compensation insurers, Medicaid MCO, multiple employer welfare arrangement or government plan or persons that self-insure without being required to obtain a separate license.

D.License renewal. To continue a license a PBM shall submit a renewal application by March 1, of each year pursuant as directed by the superintendent After the application has been approved or rejected by the PBM program coordinator, the applicant shall pay the required application fee through NIPR and shall pay the annual report fee as directed by the superintendent. Failure to pay the application fee will preclude renewal. A renewal application shall include updates to any items required by the initial application for licensure.

E.Review and approval process for renewal of license. Within 60 days of receipt of a renewal license application, the superintendent will review the application and:

(1) if the application is incomplete, notify the applicant in writing that additional information is needed, and allow the applicant 30 days to cure any deficiency in the application.

(2) approve the application and issue a PBM license to the applicant if the superintendent determines that the application meets the requirements for licensure; or

(3) deny the application if the superintendent determines that the applicant does not meet the requirements for licensure. For disapprovals or denials of an application for renewal the superintendent will notify the applicant of the denial or rejection and state the basis or reason for the denial.

F.Corrective action plan. In lieu of a denial for initial licensure or renewal, the superintendent may require the PBM to submit a plan to cure or correct deficiencies in its application.

N.M. Admin. Code § 13.10.30.8

Adopted by New Mexico Register, Volume XXXII, Issue 02, January 26, 2021, eff. 3/1/2021, Adopted by New Mexico Register, Volume XXXIII, Issue 04, February 22, 2022, eff. 3/1/2022