Be Part of the Ultimate Safety & Compliance Community
Trending news, knowledge-building content, and more – all personalized to you!
['Employee Benefits']
['Health Plans']
03/28/2024
Copyright 2024 J. J. Keller & Associate, Inc. For re-use options please contact copyright@jjkeller.com or call 800-558-5011.
...
SEARCH
Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.
New Mexico law includes the following provisions:
- The plan must not discriminate on the basis of race, color, religion, or national origin. §59A-16-12
- The plan must not discriminate on the basis of sex. §59A-16-13
- The plan must cover temporomandibular joint disorders and craniomandibular disorders, subject to the same conditions, limitations, prior review and referral procedures as are applicable to treatment of any other joint in the body. §59A-16-13.1
- The plan must not discriminate on the basis of blindness, including partial blindness. §59A-16-13.2
- The plan must not use gender as a health insurance rating factor. This applies to the New Mexico Insurance Code, Minimum Healthcare Protection Act, Small Group Rate and Renewability Act, and the Health Insurance Alliance Act. It is effective for policies issued or delivered on or after January 1, 2014. Prior to that time, there is a phase-in of this requirement, so that rates charged on the basis of gender cannot exceed rates for other similarly situated persons in the age group by more than fifteen (15) percent in calendar year 2011, ten (10) percent in 2010, and five (5) percent in 2013. §59A-18-13.1 (SB 148)
- The plan must, within the limits of coverage, allow participants freedom of choice in the selection of any hospital for hospital care or of any practitioner of the healing arts or optometrist, psychologist, podiatrist, certified nurse-midwife, registered lay midwife, or registered nurse. §59A-22-32
- The plan must, within the limits of coverage, allow participants freedom of choice in the selection of any independent social worker. §59A-22-32.1
- If the plan covers dependents, it must cover dependents, regardless of age, with mental retardation or physical handicap who are chiefly dependent upon the policyholder for support and maintenance. §59A-22-33
- If the plan covers family members, it must cover newborn children from the moment of birth, including congenital defects and birth abnormalities. If the plan does not cover family members, it must offer optional coverage for newborn children. §59A-22-34
- The plan must cover adopted children, effective as of the date of placement, on the same basis as other dependents. §59A-22-34.1
- Coverage cannot be denied to children on the grounds that the children are born out of wedlock, are not claimed as a dependent on the parent's federal return, or do not reside with the parent or in the insurer's service area. §59A-22-34.2, §59A-23-7.2
- The plan must cover childhood immunizations, as well as coverage for medically necessary booster doses of all immunizing agents used in child immunizations. §59A-22-34.3
- The plan must cover circumcision for newborn males. §59A-22-34.4, §59A-23-7.4
- The plan must offer optional home health care coverage. §59A-22-36
- The plan must cover papillomavirus screenings for women who are at least 18 years old or who are at risk; the screenings must be also be available every three years for women at least 30 years old. §59A-22-40 (§59A-46-42 for HMOs)
- The plan must cover individuals with insulin-using diabetes, with non-insulin-using diabetes and with elevated blood glucose levels induced by pregnancy, including diabetes self-management. §59A-22-41
- Plans must cover genetic inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism. §59A-22-41.1
- If the plan covers prescriptions, it must cover prescription contraceptive drugs or devices approved by the Food and Drug Administration. §59A-22-42
- The plan must cover routine patient care costs incurred as a result of the patient's participation in a cancer clinical trial, with limitations. §59A-22-43
- If the plan offers maternity benefits, it must cover smoking cessation treatment. §59A-22-44
- The plan must offer and make available benefits for the necessary care and treatment of alcohol dependency. §59A-23-6
- The plan must cover orally administered anticancer medications on a basis no less favorable than for intravenously administered or injected cancer medications that are covered as medical benefits.
- The Private Health Insurance Purchasing Co-Op Act allows both large and small (or a combination of the two) employers to form health insurance cooperatives. §59A-23
- Effective 4/7/11, dental insurance plans are prohibited from requiring participating network dentists from accepting negotiated fee allowances on noncovered dental services. §59A-22-51
- Effective 6/17/11, cooperatives may be formed for employers to purchase health benefit plans. §59A-23-11
- Effective 1/1/12, health insurance rates will be subject to review, per the federal Patient Protection and Affordable Care Act (PPACA), which requires that a process be established for reviewing increases in health plan premiums and requires plans to justify increases. §59A-18
- Effective 6/17/11, for plans issued or renewed on or after 1/1/12, coverage for cancer treatment shall cover a prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits by the plan. §59A-22, 59A-23
For information on women’s health, see the Women’s Health Rights topic.
State
Contact
Regulations
New Mexico Statutes, Chapter 59A:
- Article 22, Health Insurance Contracts
- Article 16, Trade practices and frauds
- Article 23, Group and Blanket Health Insurance Contracts
(Browse to Chapter 59A and the relevant article.)
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)
READ MORESHOW LESS
['Employee Benefits']
['Health Plans']
Load More
J. J. Keller is the trusted source for DOT / Transportation, OSHA / Workplace Safety, Human Resources, Construction Safety and Hazmat / Hazardous Materials regulation compliance products and services. J. J. Keller helps you increase safety awareness, reduce risk, follow best practices, improve safety training, and stay current with changing regulations.
Copyright 2024 J. J. Keller & Associate, Inc. For re-use options please contact copyright@jjkeller.com or call 800-558-5011.