Individual Insurance Market Rules in New Mexico
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- Can insurance companies deny me coverage?
Insurance companies can deny you coverage in New Mexico. Insurance companies are not required to sell coverage to everyone who applies. That means they can deny you coverage because of anything they find objectionable in your health history. However, in New Mexico, individual market insurance companies must sell standardized high-risk pool policies to anyone who has a pre-existing condition that makes him/her ineligible for a regular insurance policy.
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- Can insurance companies charge me more than other people for the same policy?
Insurance companies can charge you more than other people for the same policy in New Mexico. If an insurance company chooses to sell you a policy it can charge you more for the same policy if it believes you pose a higher risk of costing it money, including if you have a pre-existing condition, are older, or are a woman of childbearing age. However, New Mexico uses “health status rate bands” which limit the amount by which premiums can vary due to health status.
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- Can insurance companies exclude coverage of my pre-existing condition?
Insurance companies can permanently exclude coverage of your pre-existing condition in New Mexico. Insurance companies can permanently exclude from coverage any health problems you disclose, or they find in your medical records, at the time of application by an amendment to the individual health insurance contract. This is called an “elimination rider.” In New Mexico insurance companies cannot put an elimination rider on your policy if you previously had insurance that covered that condition.
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- Can insurance companies make up their own definition of a pre-existing condition?
Insurance companies cannot make up their own definition of a pre-existing condition in New Mexico. Insurance companies can consider something a pre-existing condition if the person received medical advice, diagnosis, care or treatment for that condition prior to enrollment in the plan. They can also consider a condition pre-existing if it was never diagnosed but you had symptoms for which an ordinary prudent person would have sought medical advice, care or treatment. This is called a “prudent person standard.”
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- Can insurance companies accept my application for coverage and later search my medical records for an excuse to deny me coverage for needed care?
Insurance companies are limited in their ability to search your medical records for an excuse to deny you coverage for needed care in New Mexico. If you make a claim for health care services during the first 6 months of coverage, the insurance company can search your medical history dating back 6 months prior to the purchase of your policy looking for evidence that your current health problem was pre-existing.
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- Can insurance companies pay their doctors incentives to provide me with less care?
Insurance companies cannot pay their doctors incentives to provide you with less care in New Mexico. An insurance company cannot pay health care providers incentives to withhold covered care.
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- Can I appeal an insurance company’s denial of care to an outside entity?
Only a member of a managed health care plan can appeal any decision to deny, reduce or terminate covered services to an outside entity in New Mexico. You can file an appeal to the Department of Insurance. The service is free but an appeal must be filed within 30 days of stage two internal review panel denial.
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- Can I sue my insurance company if it denies medically necessary care that causes me or a loved-one harm?
You cannot sue your insurance company if it denies medically necessary care that causes you or a loved-one harm in New Mexico. You cannot sue an insurance company for any harm that may have resulted from its denial of coverage or benefits.
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SOURCE: Kaiser Family Foundation State Health Facts, 2007
To learn about all your rights and protections in the individual insurance market, contact the New Mexico Public Regulation Commission.
