N.M. Admin. Code § 13.10.35.8

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

Section 13.10.35.8 - GENERAL PROHIBITED POLICY PROVISIONS

A.Probationary and waiting periods. Except as otherwise expressly allowed under Sections 10 and 11 of this rule, a plan shall not include any probationary or waiting period during which no coverage is provided for a covered benefit, except an eligibility waiting period during which no premium is paid.

B.Riders and other supplements. Any rider, amendment, endorsement or other supplement shall explicitly state which terms of coverage the carrier has amended or supplemented from the original plan.

C.Exclusions. A plan that includes any exclusions shall comply with these requirements:

(1) each plan application shall include a prominent notice that the plan includes a preexisting exclusion, and display either the full text of the exclusion or directions as to how to obtain a copy of that text.

(2) the carrier shall not enforce a preexisting condition exclusion if an enrollee renews coverage under a plan offered by the same carrier.

(3) a plan application shall not request family member health information unless the family member is also seeking coverage under the plan; and

(4) a plan may exclude benefits for the replacement of a tooth that the covered person lost prior to the covered person's plan effective date unless the covered person had coverage from a prior carrier.

D.Evidence of coverage. Upon request, a carrier shall provide a current or former enrollee evidence of that person's current or former coverage under a plan.

E.Marketing of blanket or group coverages. A carrier shall not sell any blanket coverage to a group that is not described in Section 59A-23-2 NMSA 1978, or group coverage that is not identified or described in Section 59A-23-3 NMSA 1978.

F.Arbitration provisions. A plan shall not require a covered person to submit a dispute to mediation or arbitration.

G.Plan governance. A covered person's rights under any plan shall be governed by the terms of the plan approved by the superintendent, and by applicable state and federal law.

H.Discrimination. No plan shall discriminate in eligibility for coverage or benefits on the basis of sex, sexual orientation, gender, race, religion, or national origin.

I.Conversion privileges. A carrier shall not offer a conversion plan that is not approved by the superintendent.

J.Gag rule. A plan shall not include, and a carrier shall not otherwise impose, a gag rule or practice that prohibits a dental or vision service provider from discussing a treatment option with a covered person.

N.M. Admin. Code § 13.10.35.8

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