A. Any certificate of authority issued under the provisions of the Health Maintenance Organization Law may be suspended or revoked, and any application for a certificate of authority may be denied if the superintendent finds that:
(1) the health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under Section 59A-46-3 NMSA 1978, unless amendments to such submissions have been filed with and approved by the superintendent;
(2) the health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services that does not comply with the requirements of Sections 59A-46-8 and 59A-46-16 NMSA 1978;
(3) the health maintenance organization does not provide or arrange for basic health care services;
(4) the secretary of health has certified to the superintendent that:
(a) the health maintenance organization does not meet the requirements of Paragraph (2) of Subsection A of Section 59A-46-4 NMSA 1978; or
(b) the health maintenance organization is unable to fulfill its obligations to furnish health care services;
(5) the health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(6) the health maintenance organization has failed to correct, within the time prescribed by Subsection C of this section, any deficiency occurring due to the health maintenance organization's prescribed minimum net worth being impaired;
(7) the health maintenance organization has failed to implement the grievance procedures required by Section 59A-46-11 NMSA 1978 in a reasonable manner to resolve valid complaints;
(8) the health maintenance organization, or any person on its behalf, has engaged in any practice that under Chapter 59A, Article 16 NMSA 1978 is defined or prohibited as, or determined to be, an unfair method of competition, or an unfair or deceptive act or practice, or fraudulent;
(9) the continued operation of the health maintenance organization would be hazardous to its enrollees; or
(10) the health maintenance organization has otherwise failed substantially to comply with the provisions of the Health Maintenance Organization Law.
B. In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to this section, the applicant or health maintenance organization may be subjected to an administrative penalty of up to five thousand dollars ($5,000) for each cause for suspension or revocation, but if the violation is willful or intentional, the administrative penalty may be up to ten thousand dollars ($10,000).
C. Whenever the superintendent finds that the net worth maintained by any health maintenance organization subject to the provisions of the Health Maintenance Organization Law is less than the minimum net worth required to be maintained pursuant to the provisions of Section 59A-46-13 NMSA 1978, he shall give written notice to the health maintenance organization of the amount of the deficiency and require the health maintenance organization to:
(1) file with the superintendent a plan for correction of the deficiency acceptable to the superintendent; and
(2) correct the deficiency within a reasonable time, not to exceed sixty days, unless an extension of time, not to exceed sixty additional days, is granted by the superintendent.
D. A deficiency found to exist by the superintendent pursuant to the provisions of Subsection C of this section shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority of the health maintenance organization or for placing it in conservation, rehabilitation or liquidation.
E. Unless allowed by the superintendent no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing such coverage is impaired, and the fact of such impairment is known to the health maintenance organization or to such person. However, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage.
F. A certificate of authority shall not be suspended or revoked or an application for a certificate of authority denied or an administrative penalty imposed unless:
(1) the suspension, revocation, denial or imposition is by written order and is sent to the health maintenance organization or applicant by certified or registered mail; and
(2) the written order states the grounds, charges or conduct on which the suspension, revocation, denial or imposition is based.
G. The health maintenance organization or applicant may in writing request a hearing within thirty days from the date of mailing of an order suspending or revoking a certificate of authority, denying an application or imposing an administrative penalty. If no written request is made, such order shall be final upon the expiration of the thirty days.
H. If the health maintenance organization or applicant requests a hearing pursuant to the provisions of Subsection G of this section, the superintendent shall issue a written notice of hearing and send it to the health maintenance organization or applicant by certified or registered mail stating:
(1) a specific time for the hearing, which may not be less than twenty nor more than thirty days after mailing of the notice of hearing; and
(2) a specific place for the hearing, which may be either in Santa Fe county or in the county where the health maintenance organization's or applicant's principal place of business is located.
I. After a hearing held pursuant to the provisions of Subsection H of this section or upon failure of the health maintenance organization to appear at the hearing, the superintendent shall take whatever action he deems necessary based on written findings and shall mail his decision to the health maintenance organization or applicant.
J. The provisions of Chapter 59A, Article 4 NMSA 1978 shall apply to proceedings under this section to the extent they are not in conflict with Subsection H of this section.
K. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
L. When the certificate of authority of a health maintenance organization is revoked, that organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The superintendent may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.
History: 1978 Comp., § 59A-46-20, enacted by Laws 1993, ch. 266, § 20.
Repeals and reenactments. — Laws 1993, ch. 266, § 43 repealed former 59A-46-20 NMSA 1978, as enacted by Laws 1984, ch. 127, § 867, related to administrative procedures, and Laws 1993, ch. 266, § 20 enacted a new section, effective January 1, 1994.
Structure New Mexico Statutes
Article 46 - Health Maintenance Organizations
Section 59A-46-1 - Short title.
Section 59A-46-2 - Definitions.
Section 59A-46-3 - Establishment of health maintenance organizations.
Section 59A-46-4 - Issuance of certificate of authority.
Section 59A-46-5 - Powers of health maintenance organizations.
Section 59A-46-6 - Fiduciary responsibilities; fidelity bond.
Section 59A-46-7 - Quality assurance program.
Section 59A-46-8 - Requirements for group contract, individual contract and evidence of coverage.
Section 59A-46-9 - Annual report.
Section 59A-46-10 - Information to enrollees or subscribers.
Section 59A-46-11 - Grievance procedures.
Section 59A-46-12 - Investments.
Section 59A-46-13 - Protection against insolvency.
Section 59A-46-14 - Uncovered expenditures insolvency deposit.
Section 59A-46-15 - Enrollment period; replacement coverage in the event of insolvency.
Section 59A-46-16 - Filing requirements for rating information.
Section 59A-46-17 - Regulation of health maintenance organization insurance producers.
Section 59A-46-18 - Powers of insurers.
Section 59A-46-19 - Examinations.
Section 59A-46-20 - Suspension or revocation of certificate of authority.
Section 59A-46-21 - Rehabilitation, liquidation or conservation of health maintenance organizations.
Section 59A-46-22 - Summary orders and supervision.
Section 59A-46-22.1 - Repealed.
Section 59A-46-23 - Regulations.
Section 59A-46-25 - Penalties and enforcement.
Section 59A-46-26 - Filings and reports as public documents.
Section 59A-46-26.1 - Employer utilization and loss experience availability.
Section 59A-46-27 - Confidentiality of medical information and limitation of liability.
Section 59A-46-28 - Authority to contract.
Section 59A-46-30 - Statutory construction and relationship to other laws.
Section 59A-46-31 - Coordination of benefits.
Section 59A-46-32 - Continuation of coverage and conversion rights; health care plans.
Section 59A-46-32.1 - Recompiled.
Section 59A-46-33 - Governing body.
Section 59A-46-34 - Prohibited practices.
Section 59A-46-35 - Provider discrimination prohibited.
Section 59A-46-36 - Doctor of oriental medicine; discrimination prohibited.
Section 59A-46-37 - Coverage for adopted children.
Section 59A-46-38 - Newly born children coverage.
Section 59A-46-38.1 - Coverage of children.
Section 59A-46-38.2 - Childhood immunization coverage required.
Section 59A-46-38.3 - Maximum age of dependent.
Section 59A-46-38.4 - Coverage of circumcision for newborn males.
Section 59A-46-38.5 - Hearing aid coverage for children required.
Section 59A-46-39 - Maternity transport required.
Section 59A-46-40 - Home health care service option required.
Section 59A-46-41 - Coverage for mammograms.
Section 59A-46-41.2 - Prior authorization for gynecological or obstetrical ultrasounds prohibited.
Section 59A-46-42 - Coverage for cytologic and human papillomavirus screening.
Section 59A-46-42.1 - Coverage for the human papillomavirus vaccine.
Section 59A-46-43 - Coverage for individuals with diabetes.
Section 59A-46-43.2 - Coverage for medical diets for genetic inborn errors of metabolism.
Section 59A-46-44 - Coverage for contraception.
Section 59A-46-45 - Coverage for smoking cessation treatment.
Section 59A-46-46 - Coverage of alpha-fetoprotein IV screening test.
Section 59A-46-47 - Coverage of part-time employees.
Section 59A-46-48 - Coverage of colorectal cancer screening.
Section 59A-46-49 - General anesthesia and hospitalization for dental surgery.
Section 59A-46-50 - Coverage for autism spectrum disorder diagnosis and treatment.
Section 59A-46-50.2 - Coverage of prescription eye drop refills.
Section 59A-46-50.3 - Coverage for telemedicine services.
Section 59A-46-50.4 - Prescription drugs; prohibited formulary changes; notice requirements.
Section 59A-46-52 - Prescription drug prior authorization protocols.
Section 59A-46-52.2 - Pharmacist prescriptive authority services; reimbursement parity.
Section 59A-46-53 - Pharmacy benefits; prescription synchronization.
Section 59A-46-54 - Provider credentialing; requirements; deadline.
Section 59A-46-55 - Coverage exclusion. (Contingent repeal. See note below.)
Section 59A-46-56 - Physical rehabilitation services; limits on cost sharing.