Health “STOP LOSS” or “EXCESS BENEFIT” Insurance

# STATE OF NEW MEXICO # OFFICE OF SUPERINTENDENT OF INSURANCE P.O. Box 1689, Santa Fe, NM 87504-1689 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Phone: (505) 827-4601; Fax (505) 827-4734 SUPERINTENDENT OF INSURANCE John G. Franchini (505) 827-4299  ACTING DEPUTY SUPERINTENDENT Alan Seeley (505) 827-4307 # BULLETIN NO. 2015-005 TO: EVERY INSURER, NONPROFIT HEALTH CARE PLAN, HEALTH MAINTENANCE ORGANIZATION, AND PREPAID DENTAL PLAN TRANSACTING BUSINESS IN NEW MEXICO FROM: JOHN G. FRANCHINI, SUPERINTENDENT OF INSURANCE DATE: FEBRUARY 18, 2015 RE: HEALTH "STOP LOSS" OR "EXCESS BENEFIT" INSURANCE Issued pursuant to Section 59A-2-8 NMSA 1978 of the New Mexico Insurance Code, 13.1.2 et seq. NMAC. Under New Mexico Statutes 59A-7-3.C.(2), the group health insurance coverage commonly known as "Stop Loss" or "Benefit Excess" is defined as Health Insurance, and must conform to all New Mexico Health Insurance requirements. Note in particular that: A) all such coverage issued in New Mexico is subject to state Medical Loss Ratio (MLR) requirements (NMSA 59A-22-50 "Health insurers; direct services") and must be included in all state MLR calculations, notwithstanding the federal MLR Annual Reporting Form Filing Instructions; and B) all such coverage issued in New Mexico must conform to the liability provisions of NMAC 13.10.5.11.A., commonly known as "occurrence-based" insurance. In addition, however, definition of "Stop Loss" and "Benefit Excess" as Health Insurance precludes exemption of such coverage from the Patient Protection and Affordable Care Act (ACA) requirements. Accordingly: 1. no new "Stop Loss" or "Benefit Excess" policies, contracts, or agreements may be offered or sold in New Mexico except those which are fully compliant with New Mexico and ACA requirements; addition, however, definition of "Stop Loss" and "Benefit Excess" as Health Insurance precludes exemption of such coverage from the Patient Protection and Affordable Care Act (ACA) requirements. Accordingly: 1. no new "Stop Loss" or "Benefit Excess" policies, contracts, or agreements may be offered or sold in New Mexico except those which are fully compliant with New Mexico and ACA requirements; 2. no existing "Stop Loss" or "Benefit Excess" policies, contracts, or agreements may be renewed or subjected to rate or form changes except those which are fully compliant with New Mexico and ACA requirements; and NM OFFICE OF SUPERINTENDENT OF INSURANCE 2015 FEB 19 AM 03 FILE 3. all "Stop Loss" or "Benefit Excess" policy forms and rates previously filed with and approved by NMOSI, which are not fully compliant with New Mexico and ACA requirements are invalid for use after the date of this Bulletin. ISSUED at Santa Fe, New Mexico on February 18, 2015. # OFFICE OF NEW MEXICO SUPERINTENDENT OF INSURANCE John G. Franchini Superintendent of Insurance