N.M. Admin. Code § 13.10.35.13

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

Section 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 schedule 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) cost-sharing features must be written from the perspective of the insured;

(d) where and in what manner information is available and as to how services may be obtained;

(e) a clear and understandable description of the method for resolving a covered person's complaint;

(f) a reinstatement provision which states that when premium is not paid within the applicable grace period, a subsequent acceptance of premium by the insurer or their agent without requiring an application for reinstatement, shall reinstate the policy. However, if the insurance company requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application, lacking such approval, upon the 30th day following the date of such conditional receipt unless the insurance company has previously notified the insured in writing of its disapproval of such application;

(g) a clear and understandable description of the conditions for renewal;

(h) procedures for filing claims;

(i) statement of the amounts payable to the carrier by a covered person and the times at which the amounts shall be paid;

(j) the period during which the plan is effective; and

(k) 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.

(4) PPO and indemnity plans cannot be combined and must be submitted in separate product filings.

B.Notice required. If the company sends a separate schedule of benefits to the insured, the following language shall be provided in the separately issued schedule 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.

C.Contact information. The policy, certificate and schedule of benefits, if issued separately, shall state the plan's contact information and the website and phone number for OSI.

D.Insurance cards. Basic consumer information, including the phone number and website of the insurer's consumer assistance bureau, shall be included on all newly-issued physical or digital insurance cards. Carriers may issue digital cards, but shall provide a physical card upon the request of the consumer.

N.M. Admin. Code § 13.10.35.13

Adopted by New Mexico Register, Volume XXXII, Issue 11, June 8, 2021, eff. 1/1/2022, Amended by New Mexico Register, Volume XXXIII, Issue 24, December 27, 2022, eff. 1/1/2024