N.M. Admin. Code § 13.10.34.15

Current through Register Vol. 35, No. 20, October 22, 2024

Section 13.10.34.15 - SUPPLEMENTAL PLAN

A supplemental plan is subject to these additional requirements.

A.Group coverage limitation A carrier shall only offer or issue a supplemental plan to a person who is covered under a primary group major medical, TRICARE or Champus plan.

B.Plan design A supplemental plan must be specifically designed to fill gaps in the primary coverage. This requirement is satisfied if the coverage is designed to fill gaps in cost-sharing in the primary coverage, such as coinsurance or deductibles, or the coverage is designed to provide benefits for items and services not covered by the primary coverage and that are not essential health benefits as defined under section 1302(b) of the Patient Protection and Affordable Care Act in the New Mexico benchmark plan, or the coverage is designed to both fill such gaps in cost-sharing under, and cover such benefits not covered by, the primary coverage.

C.No coordination A supplemental plan shall not include a coordination-of-benefits provision but may condition payment of benefits on the covered person becoming obligated to pay a cost-sharing obligation under the primary coverage.

D.Indemnity A supplemental plan shall not offer fixed indemnity benefits.

E.Filing requirement For each supplemental plan filed with the superintendent, the carrier shall also file a separate document specifically identifying any offered benefits that are not covered by group major medical coverage and are not essential health benefits.

F.Exclusions A supplemental plan shall include a provision that guarantees the plan will not impose an exclusion that does not appear in the covered person's group major medical plan.

N.M. Admin. Code § 13.10.34.15

Adopted by New Mexico Register, Volume XXXI, Issue 18, September 29, 2020, eff. 10/1/2020, Amended by New Mexico Register, Volume XXXIII, Issue 15, August 9, 2022, eff. 7/1/2023