A. A health insurer shall make reimbursement for direct services at a level not less than eighty-five percent of premiums across all health product lines over the preceding three calendar years, but not earlier than calendar year 2010, as determined by reports filed with the office of superintendent of insurance. Nothing in this subsection shall be construed to preclude a purchaser from negotiating an agreement with a health insurer that requires a higher amount of premiums paid to be used for reimbursement for direct services for one or more products or for one or more years.
B. An insurer that fails to comply with the eighty-five percent reimbursement requirement in Subsection A of this section shall issue a dividend or credit against future premiums to all policyholders in an amount sufficient to assure that the benefits paid in the preceding three calendar years plus the amount of the dividends or credits equal eighty-five percent of the premiums collected in the preceding three calendar years. If the insurer fails to issue the dividend or credit in accordance with the requirements of this section, the superintendent shall enforce the requirements and may pursue any other penalties as provided by law, including general penalties pursuant to Section 59A-1-18 NMSA 1978.
C. After notice and hearing, the superintendent may adopt and promulgate reasonable rules necessary and proper to carry out the provisions of this section.
D. For the purposes of this section:
(1) "direct services" means services rendered to an individual by a 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 an 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;
(2) "health insurer" means a person duly authorized to transact the business of health insurance in the state pursuant to the Insurance Code but does not include a person that only issues a limited-benefit policy intended to supplement major medical coverage, including medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income; and
(3) "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 tax paid pursuant to the Insurance Premium Tax Act [7-40-1 to 7-40-10 NMSA 1978] and fees associated with participating in a health insurance exchange that serves as a clearinghouse for insurance.
History: Laws 2010, ch. 94, § 2; 2013, ch. 74, § 28; 2018, ch. 57, § 21.
ANNOTATIONSThe 2018 amendment, effective January 1, 2020, revised the definitions of "direct services" and "premium" as used in this section; in Subsection D, Paragraph D(1), after "Medical Insurance Pool Act", deleted "or the Health Insurance Alliance Act", and in Paragraph D(3), after "interests less any", deleted "premium", and after "paid pursuant to", deleted "Section 59A-6-2 NMSA 1978" and added "the Insurance Premium Tax Act".
Temporary provisions. — Laws 2018, ch. 57, § 30 provided that:
A. On January 1, 2020, all personnel directly involved with the audit and collection of the taxes imposed pursuant to the New Mexico Insurance Code prior to the effective date of this act, functions, appropriations, money, records, furniture, equipment and other property of, or attributable to, the financial audit bureau of the office of superintendent of insurance shall be transferred to the taxation and revenue department.
B. On January 1, 2020, no contractual obligations of the office of superintendent of insurance shall be binding on the taxation and revenue department.
The 2013 amendment, effective March 29, 2013, required reports of direct services to be filed with the superintendent of insurance; and in Subsection A, in the first sentence, after "reports filed with the", added "office of superintendent of" and after "insurance", deleted "division of the commission".