What are you looking for? Patients Debt Collection Protection ActReport Insurance Fraud in New MexicoInsurance TypesTitle InsuranceHomeowners InsuranceCondo InsuranceRenters InsuranceAuto InsuranceHealth InsuranceManaged Health Care ReviewGrievance Procedures RulesWhat Consumers need to know about Surprise BillingIndependent Review OrganizationBilling ExamplesHealthcare Provider ArrangementsMultiple Employer Welfare Arrangement (MEWA)Life InsuranceOther Types of Health InsuranceStay Ready for Disasters!FloodWildfireWind & HailWinter Storm OSI Events Calendar View our calendar of events Choosing a provider can impact the amount you pay for covered services. When selecting a provider you have the choice between a Network Provider (this is a provider that has a contract with your health care plan and will provide services for a set amount that the plan and provider have agreed on, this is referred to as reasonable and customary charges) and an Out of Network provider (this is a provider that does not have a contract with your health care plan and can set there own prices of services that are being rendered). The amount that your plan is going to pay is based on the agreed upon rate between your provider and the health plan. You may be responsible for cost-sharing amounts, (Deductible, Copay, Coinsurance). Example 1. In-Network claim payment and advantages over Out of Network In Network Provider Claim Payment (80% Plan; Deductible is met)Provider’s billed charge$10,000.00R&C charges (the maximum amount that can be considered for benefit payment)$8,000.00The Health Care Plans payment to provider (80% of $8,000)$6,400.00Member coinsurance (20% of $8,000.00) applied to the out-of-pocket limit-$1,600.0Amount over the R&C charges, the consumer is responsible for all cost incurred over the R&C charges these amounts do not apply to your out of pocket limits)-$0.00With coinsurance: the total amount due would be:$1600.00Total amount due without coinsurance:$0 Example 2. Out of network claim payment and disadvantages of choosing an Out of Network provider. Example 2. Out of Network Provider Claim Payment (80% Plan; Deductible is met):Provider’s billed charge$10,000.00R&C charges (the maximum amount that can be considered for benefit payment)$8,000.00The Health Care Plans payment to provider (80% of $8,000)$6,400.00Member coinsurance (20% of $8,000.00) applied to the out-of-pocket limit-$1,600.00Amount over the R&C charges, the consumer is responsible for all cost incurred over the R&C charges these amounts do not apply to your out of pocket limits)$2,000.00With coinsurance: the total amount due would be:$3,600.00Total amount due without coinsurance:$2,000.00 Example 3In-Network Hospital(Plan Pays 90%)Out-of-Network Hospital(Plan Pays 70%)Actual Hospital Charge$10,500$10,500Amount Recognized by medical plan:$ 6,500(the discounted rate for health plan)$ 8,800 (the Reasonable & Customary charges based on standard charge for that geographic area) Plan does not recognize the $1,700 difference between the actual charge and the R&CMedical plan pays:90% of the discounted rate: $6,500 x 90% = $5,95070% of the discounted rate: $8,800 x 70% = $6,160Member pays:10% of the discounted rate: $6,500 x 10% = $65030% of R&C charges ($8,800) plus 100% of the amount over R&C ($1,700): $2,640 + $1,700 = $4,340
March 19, 2026 Bulletins REPEAL OF BULLETIN NO. 2021-026 BULLETIN 2026-006: Bulletin No. 2021-026 is hereby repealed. The process for enrollment reporting will be communicated to carriers through electronic mail and via the Office of Superintendent of Insurance website at: https://www.osi.state.nm.us/en/insurance-professionals/life-and-health-division/ For additional information about this repeal please contact the Life and Health Division at: life.health@osi.nm.gov ISSUED this 19th day of March, 2026. REPEAL OF BULLETIN […] Read More
January 30, 2026 Bulletins REPEAL OF BULLETIN NO. 2023-009 BULLETIN 2026-004: Repeal Note: This bulletin hereby repeals Bulletin No. 2023-009 issued on April 6, 2023. ISSUED this 27 day of January, 2026. REPEAL OF BULLETIN NO. 2023-009 Read More
