45th legislature - STATE OF NEW MEXICO - first session, 2001

RELATING TO HEALTH; PROVIDING REQUIREMENTS FOR DENTAL CARE SERVICES IN HEALTH CARE INSURANCE PLANS OR CONTRACTS.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

Section 1. A new section of the New Mexico Insurance Code is enacted to read:

"[NEW MATERIAL] REQUIREMENTS RELATING TO DENTAL CARE COVERAGE.--

A. A health care insurer who provides coverage for dental care may not include in the health care insurance plan or contract a provision that:

(1) prohibits a covered person from obtaining dental care services from a dentist of the person's choice, including a specialist; or

(2) restricts a covered person's right to receive full information from the person's dentist regarding the care or treatment options that the dentist believes are in the best interests of the person.

B. A health care insurance plan or contract that provides coverage for dental care services that allows the health care insurer to review a treatment plan or conduct a utilization review shall contain a provision that a treatment plan review or utilization review relating to dental care for a covered person receiving treatment in this state shall be conducted by a dentist if the claim for reimbursement or payment is denied.

C. A health care insurer may reimburse a covered person or a dentist at a different rate because of the person's choice of a dentist if the dentist is not a part of the covered person's dental network or preferred provider organization agreement. The covered expense for non-network dentists shall not be less than that allowed to a network dentist, although the covered expense may be reimbursed at a lower percentage or with higher deductibles than if the service had been provided within the network.

D. A health care insurer may not deny:

(1) dental coverage, cancel a health care insurance plan or contract, or otherwise take action against a covered person or a dentist because the person has asserted a right described in this section; or

(2) dental coverage or eligibility for dental coverage because the covered person chooses a dentist who is not a part of his dental network or a preferred provider organization agreement.

E. A covered person may bring a civil action against a health care insurer to enforce the person's rights under this section if the covered person has exhausted the administrative appeal process.

F. A dentist who treats a covered person shall not waive uncovered dental charges for which the covered person has liability because the covered person chose the dentist outside of a dental network or a preferred provider organization agreement.

G. As used in this section:

(1) "covered person" means an individual who is entitled to receive dental care provided by a health care insurer pursuant to a health care insurance plan or contract;

(2) "covered expense" means charges that are payable under plan provisions;

(3) "dentist" means a person licensed pursuant to state law to provide dental care services; and

(4) "health care insurer" means a person that has a valid certificate of authority in good standing pursuant to the Insurance Code to act as an insurer, health maintenance organization, nonprofit health care plan or prepaid dental plan."

Section 2. EFFECTIVE DATE.--The effective date of the provisions of this act is July 1, 2001.