N.M. Admin. Code § 13.10.23.11

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

Section 13.10.23.11 - NONDISCRIMINATION BY HEALTH CARE INSURERS

A. Guaranteed renewability:

(1) In addition to the guaranteed renewability provisions pertaining to individuals, pursuant to NMSA 1978, Section 59A-23E-19, and under group health plans, pursuant to NMSA 1978, Section 59A-23E-14, health care insurers through managed health care plans are prohibited from establishing rules for continued eligibility of any individual to continue to participate in a health plan based on any of the following:

(a) gender, race, color, national origin, ancestry, religion or marital status;

(b) sexual orientation;

(c) age or the age of any contracting party, or person reasonably expected to benefit from any such contract as a covered person;

(d) health status related factors, and

(e) filing of a grievance or utilization management appeal as permitted by this rule.

(2) Health status related factors include:

(a) medical condition, including both physical and mental illnesses and disability;

(b) claims experience and frequency of use of health care services;

(c) medical history;

(d) genetic information;

(e) evidence of insurability, including conditions arising out of acts of domestic violence.

B. Contract terms and premiums:

(1) A health care insurer issuing a managed health care plan shall comply with the adjusted community rating requirements as to individuals, pursuant to NMSA 1978, Section 59A-18-13.1, and as to small group employers, pursuant to NMSA 1978, Section 59A-23C-5.1.

(2) A health care insurer issuing a managed health care plan is allowed to apply premium, price or charge differentials based on a wellness program to promote health or prevent disease in a managed health care plan, in compliance with 26 CFR Part 54, 29 CFR Part 2590 and 45 CFR Part 146.

C. Providers nondiscrimination: In addition to the provisions of NMSA 1978, Section 59A-57-6, a health care insurer issuing a managed health care plan shall not discriminate against providers on the basis of religion, race, color, national origin, age, sex, marital status, disability, or sexual orientation. Selection of participating providers shall be primarily based on, but not limited to, cost and availability of covered services and the quality of services performed by the providers.

D. Genetic information and testing prohibition:

(1) In determining insurability and in processing an application for coverage for health care services under a managed health care plan, health care insurers are prohibited from:

1) requiring an individual seeking coverage to submit to genetic screening or testing;

2) taking into consideration, other than in accordance with this section, the results of genetic screening or testing;

3) making any inquiry to determine the results of genetic screening or testing; or

4) making a decision adverse to the applicant based on entries in medical records or other reports of genetic screening or testing.

(2) In developing and asking questions regarding medical histories of applicants for coverage under an individual or group managed health care plan, contract, policy, or agreement, no health care insurer shall ask for the results of any genetic screening or testing or ask questions designed to ascertain the results of any genetic screening or testing.

(3) No health care insurer shall cancel or refuse to issue or renew coverage for health care services based on the result of genetic screening or testing or the use of genetic services.

(4) No health care insurer shall deliver, issue for delivery, or renew an individual or group managed health care plan, contract, policy, or agreement in this state that limits benefits based on the results of genetic screening or testing.

(5) A health care insurer may consider the results of genetic screening or testing if the results are voluntarily submitted by an applicant for coverage or renewal of coverage and the results are favorable to the applicant.

N.M. Admin. Code § 13.10.23.11

13.10.23.11 NMAC - Rp, 13.10.13.22 NMAC, 9/1/2009