STANDARD LANGUAGE, ADMINISTRATIVE DATA AND DISCONTINUATION NOTICES

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal DEPUTY SUPERINTENDENT Jennifer A. Catechis BULLETIN 2021-017 August 12, 2021 TO: EVERY CURRENT AND PROSPECTIVE NEW MEXICO QUALIFIED HEALTH PLAN (“QHP”) ISSUER RE: STANDARD LANGUAGE, ADMINISTRATIVE DATA AND DISCONTINUATION NOTICES Over the past few weeks, the Office of Superintendent of Insurance (“OSI”) worked with QHP issuers to develop standard plan language concerning prior authorization processes and surprise billing rights. The final language appears in the forms attached to this Bulletin. Because of the looming 2022 plan year (“2022PY”) QHP certification deadline, the OSI understands that it will be administratively impractical for an issuer to amend its previously filed QHP forms to incorporate the standard language and omit any conflicting or redundant language. The Superintendent of Insurance therefore directs subject issuers not to amend previously filed QHP forms to address the standard language. Instead, a subject issuer shall endorse the standard language to each QHP using forms that substantially replicate the style of the attached forms. To ensure compliance with this requirement, a subject issuer shall file in SERFF each final version of the form that it proposes to use for review and approval by OSI. The filings are due by COB August 20, 2021. In addition to the standard language forms, the OSI has developed an administrative data template available for download using the following link: Administrative-Data-Template.xlsx. Each 2022PY issuer shall complete and file the template in SERFF, under the Supporting Documentation tab of their respective QHP binder by August 20, 2021. Finally, the OSI understands that certain 2021PY QHPs will be discontinued. An issuer who is discontinuing a QHP must crosswalk the existing enrollees to a new plan for the 2022PY following previous guidance issued by the OSI. To ensure that those enrollees receive accurate, Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us B U L L E T I N 2 0 2 1 - 0 1 7 P a g e | 2 Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us consistent and complete information concerning the discontinuation and crosswalk process, and open enrollment opportunities, the OSI developed standard discontinuation and auto renewal notice forms. Editable versions of the forms are available for download: Auto-Renewal- Letters.docx Questions concerning these directives should be directed to Viara Ianakieva at viara.ianakieva@state.nm.us. Thank you for your cooperation. ISSUED this 12th day of August, 2021. __________________________________ RUSSELL TOAL Superintendent of Insurance ENDORSEMENT [NUMBER/IDENTIFIER] THIS ENDORSEMENT MAY CHANGE YOUR AGREEMENT WITH US. IF THE TERMS OF THIS ENDORSEMENT CONFLICT WITH ANY INFORMATION IN YOUR [EOC/POLICY/CONTRACT] THE TERMS OF THIS ENDORSEMENT CONTROL. PRIOR AUTHORIZATION Prior Authorization Requirement Certain types of care require prior authorization by us. This means that you or your provider must ask us to approve the care before you receive it. A complete and current list of the services and prescription drugs that are subject to a prior authorization requirement can be found at [insert web link or identify location in EOC and drug formulary]. We may decline payment for unauthorized care. If your provider is [innetwork/contracted/participating], and you did not agree to receive unauthorized care, your provider cannot bill you for the care. If you received unauthorized care from a provider who is not [innetwork/contracted/participating] you may be fully responsible for the resulting bills. We do not require prior authorization for: • emergency services; • contraception services that are not subject to any cost-sharing; or • an obstetrical or gynecological ultrasound. However, we require authorization for continued in-patient care if you are admitted to a hospital for emergency treatment, but your condition is stabilized. You or your provider must notify us within [insert notice time limit] from when you begin receiving emergency in-patient treatment, and within [insert notice time limit] after the emergency ends and your condition stabilizes. Prior Authorization Process Your [contracted/ in-network/ preferred] provider is responsible for knowing what care requires prior authorization, and for submitting a prior authorization request to us. We will give any provider access to all necessary forms and instructions for making the request. A [non-contracted/out-of-network/non-preferred] provider is not required to submit a prior authorization request for you. If you visit one of these providers, and that provider will not submit a prior authorization request, you may submit a prior authorization request on your own behalf, or on behalf of a dependent. We will help you obtain required documents and show you the guidelines that apply to the request. However, because your provider should be able to gather required information and submit it sooner, we encourage you to have your provider request prior authorization whenever possible. Prior Authorization Review Timelines If we do not deny a complete prior authorization request within these time frames the request is automatically approved: • Urgent Care or Prescription Drugs – If you require urgent medical care, behavioral health care or a prescription drug, we will resolve the request within 24 hours. • Non-Urgent Medicine – if you do not have an urgent need for a prescription drug, we will resolve the request within three business days if your provider: o Uses the prior authorization request form approved by the New Mexico Office of Superintendent of Insurance; o Requests an exception from an established step therapy process; or o Requests to prescribe a drug that we do not usually cover. • Other Requests – We will resolve all other requests within seven (7) business days. Meeting these time frames depends on our receipt of sufficient information to evaluate the request. Our utilization management staff can answer questions your provider might have concerning required information or any aspect of the request submission process. If we require additional information to evaluate a request, we will request it from your provider. Your provider will have at least 4 hours to provide requested information in connection with an urgent prior authorization request, and at least two calendar days for any other type of request. Why We Review Our review of a prior authorization request will determine if the proposed care involves a covered service, is medically necessary and whether an alternative type of care should be pursued instead of, or before, the requested care. Our decisions concerning medical necessity and care alternatives will be guided by current clinical care standards and will be made by an appropriate medical professional. Prior authorization does not guarantee payment. We are not required to pay for an authorized service if your coverage ends before you receive the service. After Care Review If you received care without a required prior authorization, we may allow your provider to request authorization retrospectively. Our utilization management team will assist your provider in the submission of a retrospective authorization request. However, we do not routinely authorize care retrospectively. To avoid uncertainty, it is always best to request prior authorization. Behavioral Health Care Requests for behavioral health care and prescriptions are subject to the same prior and retroactive authorization processes and timelines as requests for medical care and prescriptions. Authorization Denial We will inform you in writing if we deny a prior or retroactive authorization request. Our notice to you will explain why we denied the request and will provide you with instructions for disputing our decision if you disagree. A summary of the dispute resolution process begins on page [XX] of this document. You have a right to request information about the guidance we followed to deny your request, even if you do not dispute our decision. ENDORSEMENT [NUMBER/IDENTIFIER] THIS ENDORSEMENT MAY CHANGE YOUR AGREEMENT WITH US. IF THE TERMS OF THIS ENDORSEMENT CONFLICT WITH ANY INFORMATION IN YOUR [EOC/POLICY/CONTRACT] THE TERMS OF THIS ENDORSEMENT CONTROL. OUT-OF-NETWORK CARE AND BILLS ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If you receive care under any of the circumstances below from a provider who is not in your network, these are your rights: If you receive emergency care out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an in-network provider or facility. • You do NOT need to get prior authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilization, call us at [INSERT PHONE NUMBER] and we will help you receive that care from an in-network provider. • You cannot be balance billed. If you receive care from an out-of-network provider at an in-network facility, such as a hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an innetwork provider if: • you did not consent to services from an out-of-network provider, • were not offered the service from an in-network provider, or • the service was not available from an in-network provider – as determined by your health care provider and your health insurance company. If you get a bill from an out-of-network provider under any of the above circumstances that you do not believe is owed: • Call us first at [INSERT PHONE NUMBER]. We will try to the resolve the issue with the provider on your behalf. • Contact the New Mexico Office of Superintendent of Insurance if the problem has not been resolved by us – www.osi.state.nm.us or 1-855-4ASK-OSI (1-855-427-5674). To help stop improper out-of-network bills, we will: • Notify you if your provider leaves our network and allow you transitional care with that provider at the in-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our provider directory information at least every 90 days. • Confirm whether a provider is in-network if you contact us at [INSERT PHONE NUMBER]. If our representative provides inaccurate information that you rely on in choosing a provider, you will only be responsible for paying your in-network cost sharing amount for care received from that provider. You have the right to receive notice of the following before you receive out-of-network care at an innetwork facility: • A good faith estimate of the charges for out-of-network care. • At least five days to change your mind before you receive a scheduled out-of-network service. If you choose to receive out of network care you will be responsible for out-of-network charges that we do not cover. • A list of [in-network/contracted/participating] providers and the option to be referred to any such provider who can provide necessary care. If you pay an out-of-network provider more than we determine you owe: • The provider will owe you a refund within 45 days of receipt of payment by us. • If you do not receive a refund within that 45-day period, the provider will owe you the refund plus interest. • You may contact the New Mexico Office of Superintendent of Insurance at www.osi.state.nm.us and 1-855-4ASK-OSI (1-855-427-5674) for assistance or to appeal the provider’s failure to provide a refund. You need to file the appeal within 180 days of the 45- day refund period expiration.