2021 New Mexico Statutes
Chapter 59A - Insurance Code
Article 47 - Nonprofit Health Care Plans
Section 59A-47-3 - Definitions.
A. "acquisition expenses" includes all expenses incurred in connection with the solicitation and enrollment of subscribers;
B. "administration expenses" means all expenses of the health care plan other than the cost of health care expense payments and acquisition expenses;
C. "agent" means a person appointed by a health care plan authorized to transact business in this state to act as its representative in any given locality for soliciting health care policies and other related duties as may be authorized;
D. "chiropractor" means any person holding a license provided for in the Chiropractic Physician Practice Act [Chapter 61, Article 4 NMSA 1978];
E. "credentialing" means the process of obtaining and verifying information about a provider and evaluating that provider when that provider seeks to become a participating provider;
F. "direct services" means services rendered to an individual by a health care plan, 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 a health care plan or a health insurer does not receive a tax credit pursuant to the Medical Insurance Pool Act [Chapter 59A, Article 54 NMSA 1978]; provided, however, that "direct services" does not include care coordination, utilization review or management or any other activity designed to manage utilization or services;
G. "doctor of oriental medicine" means any person licensed as a doctor of oriental medicine under the Acupuncture and Oriental Medicine Practice Act [Chapter 61, Article 14A NMSA 1978];
H. "health care" means the treatment of persons for the prevention, cure or correction of any illness or physical or mental condition, including optometric services;
I. "health care expense payment" means a payment for health care to a purveyor on behalf of a subscriber, or such a payment to the subscriber;
J. "health care plan" means an organization that demonstrates to the superintendent that it has been granted exemption from the federal income tax by the United States commissioner of internal revenue as an organization described in Section 501(c)(3) of the United States Internal Revenue Code of 1986, as that section may be amended or renumbered, and is authorized by the superintendent to enter into contracts with subscribers and to make health care expense payments, including an organization that issues:
(1) a short-term health care plan;
(2) an excepted benefit health care plan intended to supplement major medical coverage, including medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies; or
(3) a policy or plan for long-term care or disability income;
K. "indemnity benefit" means a payment that the purveyor has not agreed to accept as payment in full for health care furnished the subscriber;
L. "item of health care" means a service or material used in health care;
M. "pharmacist" means a person licensed as a pharmacist pursuant to the Pharmacy Act [Chapter 61, Article 11 NMSA 1978];
N. "pharmacist clinician" means a pharmacist who exercises prescriptive authority pursuant to the Pharmacist Prescriptive Authority Act [61-11B-1 to 61-11B-3 NMSA 1978];
O. "premium" means all income received from individuals and private and public payers or sources for the procurement of health coverage, including capitated payments, self-funded administrative fees, self-funded claim reimbursements, recoveries from third parties or other insurers and interests less any premium tax paid pursuant to Section 59A-6-2 NMSA 1978 and fees associated with participating in a health insurance exchange that serves as a clearinghouse for insurance;
P. "provider" means a physician or other individual licensed or otherwise authorized to furnish health care services in the state;
Q. "purveyor" means a person who furnishes any item of health care and charges for that item;
R. "service benefit" means a payment that the purveyor has agreed to accept as payment in full for health care furnished the subscriber;
S. "short-term health care plan" means a nonrenewable health care plan covering a resident of the state, regardless of where the plan is delivered, that:
(1) has a maximum specified duration of not more than three months after the effective date of the plan; and
(2) is issued only to individuals who have not been enrolled in a health care plan that provides the same or similar nonrenewable coverage from any nonprofit health care plan within the three months preceding enrollment in the short-term plan;
T. "solicitor" means a person employed by the licensed agent of a health care plan for the purpose of soliciting health care policies and other related duties in connection with the handling of the business of the agent as may be authorized and paid for the person's services either on a commission basis or salary basis or part by commission and part by salary;
U. "subscriber" means any individual who, because of a contract with a health care plan entered into by or for the individual, is entitled to have health care expense payments made on the individual's behalf or to the individual by the health care plan; and
V. "underwriting manual" means the health care plan's written criteria, approved by the superintendent, that defines the terms and conditions under which subscribers may be selected. The underwriting manual may be amended from time to time, but the amendment will not be effective until approved by the superintendent. The superintendent shall notify the health care plan filing the underwriting manual or the amendment thereto of the superintendent's approval or disapproval thereof in writing within thirty days after filing or within sixty days after filing if the superintendent shall so extend the time. If the superintendent fails to act within such period, the filing shall be deemed to be approved.
History: Laws 1984, ch. 127, § 879.1; 1989, ch. 96, § 3; 1993, ch. 158, § 5; 2007, ch. 244, § 2; 2015, ch. 111, § 5; 2018, ch. 57, § 25; 2019, ch. 235, §13; 2019, ch. 235, § 14.
ANNOTATIONSCross references. — For the United States Internal Revenue Code of 1986, see 26 U.S.C.
The 2019 second amendment, effective January 1, 2020, added the definitions of certain terms as used in Chapter 59A, Article 47 NMSA 1978; added new Subsections A through G and redesignated former Subsection A as Subsection H; deleted former Subsection B; redesignated former Subsection C as Subsection I; added new Subsections J through P and redesignated former Subsections D and E as Subsections Q and R, respectively; deleted former Subsection F; added new Subsections S and T and redesignated former Subsections G and H as Subsections U and V, respectively; and deleted former Subsections I through S.
The first 2019 amendment, effective June 14, 2019, added the definitions of certain terms as used in Chapter 59A, Article 47 NMSA 1978; added new Subsections A through G and redesignated former Subsection A as Subsection H; added new Subsections I through K and redesignated former Subsection B as Subsection L; deleted former Subsection C; added new Subsections M through P and redesignated former Subsections D and E as Subsections Q and R, respectively; deleted former Subsection F; added new Subsections S and T and redesignated former Subsections G and H as Subsections U and V, respectively; and deleted former Subsections I through S.
The 2018 amendment, effective January 1, 2020, revised the definitions of "health care plan" as used in Chapter 59A, Article 47; in Subsection K, after "'health care plan' means", deleted "a nonprofit corporation" and added "an organization that demonstrates to the superintendent that it has been granted exemption from the federal income tax by the United States commissioner of internal revenue as an organization described in Section 501(c)(3) of the United States Internal Revenue Code of 1986, as that section may be amended or renumbered, and is".
The 2015 amendment, effective June 19, 2015, defined "credentialing" and "provider" as used in the Nonprofit Health Care Plan Law; in Subsection P, after "Pharmacy Act;", deleted "and"; and added new Subsections R and S, defining "credentialing" and "provider", respectively.
The 2007 amendment, effective June 15, 2007, added the definitions of "pharmacist" and "pharmacist clinician" in new Subsections P and Q.
The 1993 amendment, effective June 18, 1993, in Subsection D, substituted "means a person" for "means any person" and substituted "and charges for that item" for "and who charges therefor, whether located within or without the state"; substituted "that" for "which" in Subsections E, F, and H; deleted "which is" preceding "authorized" in Subsection K; substituted "and other related duties as may be authorized" for "and such other duties in connection therewith as may be authorized" in Subsection L; substituted "and other related duties" for "and such other duties" in Subsection M; and rewrote Subsection O.
Law reviews. — For note, "Nonprofit Health Care Corporations Are Not Insurance Providers," see 10 N.M.L. Rev. 481 (1980).
