Plan types (indemnity, HMO, PPO, POS, HDHP/HSA), cost sharing and the federal Affordable Care Act rules are covered in the national Medical Plans guide. This guide covers what New Mexico adds: its rating and renewability rules, the prompt-pay interest law, required benefits and options that show up on the exam, and the rules for children and Medicaid. Citations are to the New Mexico Statutes (NMSA 1978).

Rating and renewability

• Adjusted community rating: for the initial premium on major medical coverage, an insurer may use only age, geographic area and smoking practices. Rates within a rating band may not differ by more than 250% (NMSA 1978, 59A-18-13.1).
• Guaranteed renewable: individual coverage renews at the individual's option. The issuer may nonrenew only for reasons such as nonpayment, fraud, leaving the market, or the person moving out of a network's service area (NMSA 1978, 59A-23E-19(B)).
• Leaving the market: an issuer that discontinues all its individual coverage gives 180 days' notice and can't re-enter that market for five years (NMSA 1978, 59A-23E-19(D)).
• Misstatements in major medical applications: a non-willful, non-fraudulent misstatement can't void comprehensive major medical coverage from issue. The issuer may charge the correct premium going forward (NMSA 1978, 59A-22-5(A)).

Prompt payment of claims

A health plan that doesn't pay a clean claim on time owes interest of 1.5% a month (NMSA 1978, 59A-16-21.1(B)). The clock is:

Required benefits and options

• Mammograms: a baseline at ages 35 to 39, one every two years at 40 to 49, and one every year at 50 and over (NMSA 1978, 59A-22-39).
• Home health care option: must cover at least 100 home visits per insured per year, each up to four hours (NMSA 1978, 59A-22-36(D)).
• Family, Infant, Toddler (FIT) program: coverage up to $3,500 a year, which doesn't count against lifetime or annual limits (NMSA 1978, 59A-22-34.2(E)).

Children and dependents

• Age 26: dependent coverage can't end because of age before the 26th birthday, whether or not the dependent is a student (NMSA 1978, 59A-22-30.1; 59A-23-7.3).
• Disabled children: coverage continues past the limiting age for a child who can't support themselves because of a disability and is chiefly dependent on the insured, with proof due within 31 days (NMSA 1978, 59A-22-33).
• Newborns: family coverage pays for a newborn from the moment of birth, including congenital defects, birth abnormalities and transport to a tertiary care facility when needed. If an added premium applies, the insurer may require notice and payment within 31 days (NMSA 1978, 59A-22-34).
• Adopted children: covered on the same basis as other dependents from placement for adoption, including conditions that existed before placement (NMSA 1978, 59A-22-34.1).
• An insurer can't refuse to enroll a child because the child was born outside marriage, isn't claimed on the parent's tax return, or doesn't live with the parent or in the service area (NMSA 1978, 59A-22-34.2(A)).

Medicaid

A health policy can't deny or limit benefits because the insured is eligible for or has received Medicaid. If Medicaid already paid, the insurer reimburses the state (NMSA 1978, 59A-22-38(D)).

Who can sell HMO coverage

Anyone paid to solicit or accept HMO membership applications from the public must hold a health insurance producer license (13.4.2.8(A)(1) NMAC; NMSA 1978, 59A-46-17).

Common exam traps

• Prompt-pay interest: 1.5% a month, starting after 30 days (electronic), 45 days (paper) or 14 days (pharmacy).
• Age 26 applies whether or not the child is a student.
• Newborn notice: 31 days if an added premium is due.
• Mammogram schedule: baseline 35-39, every two years 40-49, every year from 50.
• Adjusted community rating factors are age, area and smoking, with a 250% band limit.
• Leaving the individual market: 180 days' notice and a 5-year bar on returning.