2019 New Mexico Statutes
Chapter 59A - Insurance Code
Article 18 - The Insurance Contract
Section 59A-18-13.3 - Health insurance filings; grounds and procedure for approval or disapproval.
A. The superintendent shall issue a final order within sixty days of the filing date for health insurance filings made on rates. The superintendent shall consider any public comment made pursuant to Subsection H of Section 59A-18-13.2 NMSA 1978. The superintendent shall issue findings and shall approve any rates on the following grounds:
(1) the proposed rate is in compliance with federal law and the Insurance Code;
(2) the proposed rate does not contain, or incorporate by reference, any inconsistent, ambiguous or misleading clause, exception or condition that deceptively affects the risk purported to be assumed in the general coverage of the contract or that encourages misrepresentation of the policy or its benefits;
(3) the proposed rate is actuarially sound and is supported by the actuarial memorandum submitted;
(4) the proposed rate is reasonable, not excessive or inadequate and not unfairly discriminatory; and
(5) the proposed rate is based upon administrative expenses that are permitted by federal and state law.
B. In order to determine whether the proposed rates are reasonable, actuarially sound and based on reasonable administrative expenses, the superintendent shall consider, at a minimum:
(1) the financial position of the insurer's insurance operations in the state, including surplus and reserves as reported in the latest three years' financial statements filed by the insurer;
(2) information provided to the superintendent for calculation of the amount of the insurer's direct services reimbursement pursuant to Section 59A-22-50, 59A-23C-10, 59A-46-51 or 59A-47-46 NMSA 1978;
(3) any anticipated change in the number of enrollees if the proposed rate is approved;
(4) changes to covered benefits or health benefit plan design;
(5) the insurer's compliance with all federal and state requirements for pooling risk and for participation in risk adjustment programs in effect under federal and state law; and
(6) the reliability and accuracy of the information provided in order to assure a meaningful review.
C. No final order shall be issued until after the close of the public comment period pursuant to Subsection H of Section 59A-18-13.2 NMSA 1978.
D. In rate filings for which the superintendent holds a hearing on reconsideration pursuant to Section 59A-4-15 NMSA 1978, the superintendent shall issue a final order within sixty days of the hearing.
E. A final order of the superintendent under this section may be appealed to the court of appeals pursuant to the provisions of Section 59A-18-13.5 NMSA 1978 within twenty days.
F. As used in this section, "health insurance" or "health care plan" means a hospital and medical expense- incurred policy, plan or contract offered by a health insurer; nonprofit health service provider; health maintenance organization; managed care organization; or provider service organization; "health insurance" or "health care plan" does not include an individual policy intended to supplement major medical group-type coverage such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.
History: Laws 2011, ch. 144, § 6; 2013, ch. 74, § 23.
ANNOTATIONSThe 2013 amendment, effective March 29, 2013, provided for appeals from orders of the superintendent of insurance to the court of appeals; in Subsection A, in the second sentence of the introductory paragraph, after "Section", deleted "5 of this 2011 act" and added "59A-18-13.2 NMSA 1978"; in Subsection C, after "Section", deleted "5 of this 2011 act" and added "59A-18-13.2 NMSA 1978"; and in Subsection E, after "appealed to the", deleted "commission" and added "court of appeals" and after "Section", deleted "7 of this 2011 act" and added "59A-18-13.5 NMSA 1978".
