A. Every group and individual contract holder is entitled to a group or individual contract. The contract shall not contain provisions or statements that are unjust, unfair, inequitable, misleading, deceptive or that encourage misrepresentation as described in Section 59A-16-4 NMSA 1978. The contract shall contain a clear statement of the following:

(1) name and address of the health maintenance organization;

(2) eligibility requirements;

(3) benefits and services within the service area;

(4) emergency care benefits and services;

(5) out-of-area benefits and services, if any;

(6) copayments, deductibles or other out-of-pocket expenses;

(7) limitations and exclusions;

(8) enrollee termination;

(9) enrollee reinstatement, if any;

(10) claims procedures;

(11) enrollee grievance procedures;

(12) continuation of coverage;

(13) conversion;

(14) extension of benefits, if any;

(15) coordination of benefits, if applicable;

(16) subrogation, if any;

(17) description of the service area;

(18) entire contract provision;

(19) term of coverage;

(20) cancellation of group or individual contract holder;

(21) renewal;

(22) reinstatement of group or individual contract holder, if any;

(23) grace period; and

(24) conformity with state law.

B. An evidence of coverage may be filed as part of the group contract to describe the provisions required in Paragraphs (1) through (17) and (20) of Subsection A of this section.

C. In addition to those provisions required in Paragraphs (1) through (24) of Subsection A of this section, an individual contract shall provide for a ten-day period to examine and return the contract and have the premium refunded. If services were received during the ten-day period, and the person returns the contract to receive a refund of the premium paid, he or she must pay for such services.

D. Every subscriber shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements that are unfair, unjust, inequitable, misleading, deceptive or that encourage misrepresentation as described in Section 59A-16-4 NMSA 1978. The evidence of coverage shall contain a clear statement of the provisions required in Paragraphs (1) through (17) and (20) of Subsection A of this section.

E. The superintendent may adopt regulations establishing readability standards for individual contract, group contract and evidence of coverage forms.

F. No group or individual contract, evidence of coverage or amendment thereto shall be delivered or issued for delivery in this state, unless its form has been filed with and approved by the superintendent, subject to Subsections G and H of this section.

G. If an evidence of coverage issued pursuant to and incorporated in a contract issued in this state is intended for delivery in another state and the evidence of coverage has been approved for use in the state in which it is to be delivered, the evidence of coverage need not be submitted to the superintendent for approval.

H. Every form of group or individual contract, evidence of coverage or amendment thereto required to be filed pursuant to the provisions of Subsection F of this section shall be filed with the superintendent not less than thirty days prior to delivery or issue for delivery in this state. At any time during the initial thirty day period, the superintendent may extend the period for review for an additional thirty days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the superintendent has taken no action. The filer must notify the superintendent in writing prior to using a form that is deemed approved.

I. At any time, after thirty days notice and for cause shown, the superintendent may withdraw approval of any form of group or individual contract, evidence of coverage or amendment thereto, effective at the end of the thirty-day notice period.

J. When a filing is disapproved or approval of a form of group or individual contract, evidence of coverage or amendment thereto is withdrawn, the superintendent shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty days of receipt of the notice the health maintenance organization may request a hearing. A hearing shall be conducted within thirty days after the superintendent has received the request for hearing.

K. The superintendent may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.

History: 1978 Comp., § 59A-46-8, enacted by Laws 1993, ch. 266, § 8.

Repeals and reenactments. — Laws 1993, ch. 266, § 43 repealed former 59A-46-8 NMSA 1978, as amended by Laws 1986, ch. 51, § 2, related to evidence of coverage and charges for health care services, and Laws 1993, ch. 266, § 8 enacted a new section, effective January 1, 1994.