N.M. Admin. Code § 13.10.27.7

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

Section 13.10.27.7 - DEFINITIONS

As used in this rule:

A."health insurer" means a person duly authorized to transact the business of health insurance in the state pursuant to the Insurance Code but does not include a person that only issues an excepted benefit policy intended to supplement major medical coverage, including Medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income;

B."direct services" means services rendered to an individual by a health insurer or a health care practitioner, facility or other provider, including case management, disease management, health education and promotion, preventive services, quality incentive payments to providers and any portion of an assessment that covers services rather than administration and for which an insurer does not receive a tax credit pursuant to the Medical Insurance Pool Act or the Health Insurance Alliance Act; provided, however, that "direct services" does not include care coordination, utilization review or management or any other activity designed to manage utilization or services;

C."health care plan" has the definition found in Subsection J of Section 59A-47-3 NMSA 1978;

D."health maintenance organization" has the definition found in Subsection O of Section 59A-46-2 NMSA 1978;

E."premium" has the definition found in Paragraph (3) of Subsection E of Section 59A-22-50 NMSA 1978;

F."individually underwritten" means any health care policy, plan or contract issued to an individual or family reflecting the characteristics of the family members covered; these characteristics include, but are not limited to, place of residence, age, gender, and health status;

G."carrier" means health maintenance organization, health care plan, and health insurer;

H."minimum medical loss ratio" means the percentage determined in accordance with section 8 of this rule;

I. "health product lines" means:

(1) all programs utilized by a health insurer for the offering of products, including but not limited to:

(a) all private programs, including individual, small group and large group;

(b) all public programs, including all Medicaid and Medicare and any related or future programs or products;

(c) all other arrangements for the procurement of health coverage, including capitated arrangements, self-funded arrangements; and

(d) such other programs or arrangements that the superintendent may designate by order or bulletin; but not

(2) programs of HIPAA-excepted benefits intended to supplement major medical coverage, including Medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or policies for long-term care or disability income;

J."product" means any policy, plan or contract related to the provision of health care services offered, arranged or facilitated by an insurer, including blanket health insurance; and

K."blanket health insurance" has the definition found in Subsection A of Section 59A-23-2 NMSA 1978.

N.M. Admin. Code § 13.10.27.7

13.10.27.7 NMAC - N, 11/30/12, Amended by New Mexico Register, Volume XXXI, Issue 14, July 28, 2020, eff. 8/1/2020