NMSA 1978, § 59A-46-1 Short title
59A-46-1. Short title
Chapter 59A, Article 46 NMSA 1978 may be cited as the "Health Maintenance Organization Law".
Laws 1984, ch. 127, § 848; 1993, ch. 266, § 1.
Health Maintenance Organizations
NMSA 1978 ch. 59A, art. 46
in effectNMSA 1978, § 59A-46-2 Definitions
59A-46-2. Definitions
As used in the Health Maintenance Organization Law:
A. "basic health care services" means medically necessary services consisting of preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory, diagnostic and therapeutic radiological services and services of pharmacists and pharmacist clinicians;
B. "capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided and includes the cost associated with operating staff model facilities;
C. "carrier" means a health maintenance organization, an insurer, a nonprofit health care plan or other entity responsible for the payment of benefits or provision of services under a group contract;
D. "copayment" means an amount an enrollee must pay in order to receive a specific service that is not fully prepaid;
E. "credentialing" means the process of obtaining and verifying information about a provider and evaluating that provider when that provider seeks to become a participating provider;
F. "deductible" means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment;
G. "direct services" means services rendered to an individual by a carrier or a health care practitioner, facility or other provider, which services include case management, disease management, health education and promotion, preventive services, quality incentive payments to providers and any proportion of an assessment that covers services rather than administration and for which a carrier does not receive a tax credit pursuant to the Medical Insurance Pool Act; provided that "direct services" does not include care coordination, utilization review or management or any other activity designed to manage utilization or services;
H. "enrollee" means an individual who is covered by a health maintenance organization;
I. "evidence of coverage" means a policy, contract or certificate showing the essential features and services of the health maintenance organization coverage that is given to the subscriber by the health maintenance organization or by the group contract holder;
J. "extension of benefits" means the continuation of coverage under a particular benefit provided under a contract or group contract following termination with respect to an enrollee who is totally disabled on the date of termination;
K. "grievance" means a written complaint submitted in accordance with the health maintenance organization's formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization relative to the enrollee;
L. "group contract" means a contract for health care services that by its terms limits eligibility to members of a specified group and may include coverage for dependents;
M. "group contract holder" means the person to whom a group contract has been issued;
N. "health care services" means any services included in the furnishing to any individual of medical, mental, dental, pharmaceutical or optometric care or hospitalization or nursing home care or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing or healing human physical or mental illness or injury;
O. "health maintenance organization" means a person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles, including a carrier that issues:
(1) a short-term contract;
(2) an excepted benefit policy or contract intended to supplement major medical coverage, including medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies; or
(3) a policy for long-term care or disability income;
P. "health maintenance organization agent" means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership or who takes or transmits a membership fee or premium for such a policy or contract, other than for that person, or a person who advertises or otherwise makes any representation to the public as such;
Q. "individual contract" means a contract for health care services issued to and covering an individual and it may include dependents of the subscriber;
R. "insolvent" or "insolvency" means that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction;
S. "managed hospital payment basis" means agreements in which the financial risk is related primarily to the degree of utilization rather than to the cost of services;
T. "net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt;
U. "participating provider" means a provider as defined in Subsection Z of this section that, under an express contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization;
V. "person" means an individual or other legal entity;
W. "pharmacist" means a person licensed as a pharmacist pursuant to the Pharmacy Act;
X. "pharmacist clinician" means a pharmacist who exercises prescriptive authority pursuant to the Pharmacist Prescriptive Authority Act;
Y. "premium" means all income received from individuals and private and public payers or sources for the procurement of health coverage, including capitated payments, self-funded administrative fees, self-funded claim reimbursements, recoveries from third parties or other carriers and interests less any premium tax paid pursuant to Section 59A-6-2 NMSA 1978 and fees associated with participating in a health insurance exchange that serves as a clearinghouse for insurance;
Z. "provider" means a physician, pharmacist, pharmacist clinician, hospital or other person licensed or otherwise authorized to furnish health care services;
AA. "replacement coverage" means the benefits provided by a succeeding carrier;
BB. "short-term contract" means a nonrenewable health maintenance organization contract covering a resident of the state, regardless of where the contract is delivered, that:
(1) has a maximum specified duration of not more than three months after the effective date of the contract; and
(2) is issued only to individuals who have not been enrolled in a health maintenance organization contract that provides the same or similar nonrenewable coverage from any carrier within the three months preceding enrollment in the short-term contract;
CC. "subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization or, in the case of an individual contract, the person in whose name the contract is issued; and
DD. "uncovered expenditures" means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization's insolvency and for which no alternative arrangements have been made that are acceptable to the superintendent.
1978 Comp., § 59A-46-2, enacted by Laws 1993, ch. 266, § 2; 2007, ch. 244, § 1; 2015, ch. 111, § 3; 2019, ch. 235, § 10; 2019, ch. 259, § 17.
NMSA 1978, § 59A-46-3 Establishment of health maintenance organizations
59A-46-3. Establishment of health maintenance organizations
A. Notwithstanding any law of this state to the contrary, any person may apply to the superintendent for a certificate of authority to establish and operate a health maintenance organization in compliance with Chapter 59A, Article 46 NMSA 1978. No person shall establish or operate a health maintenance organization in this state without obtaining a certificate of authority under Chapter 59A, Article 46 NMSA 1978. A foreign corporation may qualify under Chapter 59A, Article 46 NMSA 1978, subject to its registration to do business in this state as a foreign corporation pursuant to Chapter 53, Article 17 NMSA 1978 and compliance with all provisions of Chapter 59A, Article 46 NMSA 1978 and other applicable state laws.
B. Any health maintenance organization that has not previously received a certificate of authority to operate as a health maintenance organization as of January 1, 1994 shall submit an application for a certificate of authority under Subsection C of this section no later than March 1, 1993. Each such applicant may continue to operate until the superintendent acts upon the application. In the event that an application is denied under Section 59A-46-4 NMSA 1978, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked.
C. Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the superintendent and shall set forth or be accompanied by the following:
(1) a copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement or other applicable documents and all amendments thereto;
(2) a copy of the bylaws, rules and regulations or similar document, if any, regulating the conduct of the internal affairs of the applicant;
(3) a list of the names, addresses and official positions and biographical information on forms acceptable to the superintendent of the persons who are to be responsible for the conduct of the affairs and day to day operations of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee and the principal officers in the case of a corporation or the partners or members in the case of a partnership or association;
(4) a copy of any contract form made or to be made between any class of providers and the health maintenance organization and a copy of any contract made or to be made between third party administrators, marketing consultants or persons listed in Paragraph (3) of this subsection and the health maintenance organization;
(5) a copy of the form of evidence of coverage to be issued to the enrollees;
(6) a copy of the form of group contract, if any, to be issued to employers, unions, trustees or other organizations;
(7) financial statements showing the applicant's assets, liabilities and sources of financial support, including both a copy of the applicant's most recent, regular certified financial statement and an unaudited current financial statement;
(8) a financial feasibility plan that includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve months of operations certified by an actuary or other person determined by the superintendent to be qualified, a three-year projection of balance sheets, a three-year projection of cash flow statements showing any capital expenditures, purchase and sale of investments and deposits with the state and income and expense statements anticipated from the start of operations for three years or until the organization has had net income for at least one year, if longer, a description of the proposed method of marketing and a statement of the sources of working capital as well as any other sources of funding;
(9) a power of attorney duly executed by the applicant, if not domiciled in this state, appointing the superintendent, his successors in office and duly authorized deputies as the true and lawful attorney of such applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;
(10) a statement or map reasonably describing the geographic area or areas to be served;
(11) a description of the internal grievance procedures to be utilized for the investigation and resolution of enrollee complaints and grievances;
(12) a description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, procedures for comprehensive evaluation of the quality of care rendered to enrollees and processes to initiate corrective action and reevaluation when deficiencies in provider or organizational performance are identified;
(13) a description of the procedures to be implemented to meet the protection against insolvency requirements in Section 59A-46-13 NMSA 1978;
(14) a list of the names, addresses and license numbers of all providers with which the health maintenance organization has agreements; and
(15) such other information as the superintendent may require to make the determinations required in Section 59A-46-4 NMSA 1978.
D. A health maintenance organization shall, unless otherwise provided for in Chapter 59A, Article 46 NMSA 1978, file a notice describing any substantial modification of the operation set out in the information required by Subsection C of this section. Such notice shall be filed with the superintendent prior to the modification. If the superintendent does not disapprove within thirty days of filing, such modification shall be deemed approved.
1978 Comp., § 59A-46-3, enacted by Laws 1993, ch. 266, § 3.
NMSA 1978, § 59A-46-4 Issuance of certificate of authority
59A-46-4. Issuance of certificate of authority
A. Upon receipt of an application for issuance of a certificate of authority, the superintendent may transmit copies of such application and accompanying documents to the secretary of health.
B. If requested by the superintendent, the secretary of health shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished, has complied with Section 59A-46-7 NMSA 1978.
C. If requested by the superintendent, the secretary of health shall certify to the superintendent, within forty-five days of receipt of the application for issuance of a certificate of authority, that the proposed health maintenance organization meets the requirements of Section 59A-46-7 NMSA 1978 or notify the superintendent that the health maintenance organization does not meet such requirements and specify in what respects it is deficient.
D. The superintendent shall within forty-five days of receipt of certification or notice of deficiencies from the secretary of health pursuant to Subsection C of this section, or within sixty days of receipt of the application indicated in Subsection A of this section if no request has been made of the secretary of health, issue a certificate of authority to any person filing a completed application upon receiving the prescribed fees and upon the superintendent being satisfied that:
(1) the persons responsible for the conduct of the affairs of the applicant are competent, trustworthy and possess good reputations;
(2) any deficiencies identified by the secretary of health pursuant to Subsection C of this section have been corrected and the secretary of health has certified to the superintendent that the health maintenance organization's proposed plan of operation meets the requirements of Section 59A-46-7 NMSA 1978;
(3) the health maintenance organization will effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments or deductibles, or both; and
(4) the health maintenance organization is in compliance with Sections 59A-46-13 and 59A-46-15 NMSA 1978 [repealed].
E. A certificate of authority shall be denied only after the superintendent complies with the requirements of Section 59A-46-20 NMSA 1978.
1978 Comp., § 59A-46-4, enacted by Laws 1993, ch. 266, § 4.
NMSA 1978, § 59A-46-5 Powers of health maintenance organizations
59A-46-5. Powers of health maintenance organizations
A. The powers of a health maintenance organization include, but are not limited to, the following:
(1) the purchase, lease, construction, renovation, operation or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and such property as may reasonably be required for its principal office or for such purposes as may be necessary in the transaction of the business of the organization;
(2) transactions between or among affiliated entities, including loans and the transfer of responsibility under all contracts, including without limitation provider and subscriber contracts between or among affiliates or between the health maintenance organization and its parent;
(3) the furnishing of health care services through providers, provider associations or agents for providers that are under contract with or employed by the health maintenance organization;
(4) the contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration;
(5) the contracting with an authorized insurer in this state for the provision of insurance, indemnity or reimbursement against the cost of health care services provided by the health maintenance organization;
(6) the offering of other health care services, in addition to basic health care services; and
(7) the joint marketing of products with an insurer authorized to do business in this state as long as the company that is offering each product is clearly identified.
B. A health maintenance organization shall file notice, with adequate supporting information, with the superintendent prior to the exercise of any power granted in Paragraph (1), (2) or (4) of Subsection A of this section that may affect the financial soundness of the health maintenance organization. The superintendent shall disapprove such exercise of power only if in his opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the superintendent does not disapprove within thirty days of the filing, it shall be deemed approved, but the superintendent may in his sole discretion postpone the action for an additional thirty days as necessary for proper consideration of the effects of the proposed action.
C. The superintendent may adopt rules and regulations exempting from the filing requirement of Subsection B of this section those activities having a de minimis effect.
1978 Comp., § 59A-46-5, enacted by Laws 1993, ch. 266, § 5.
NMSA 1978, § 59A-46-6 Fiduciary responsibilities; fidelity bond
59A-46-6. Fiduciary responsibilities; fidelity bond
A. Any director, officer, employee or partner of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of the organization shall be responsible for such funds in a fiduciary relationship to the organization.
B. A health maintenance organization shall maintain in force a fidelity bond or fidelity insurance on the employees and officers, directors and partners described in Subsection A of this section in an amount not less than two hundred fifty thousand dollars ($250,000) for each health maintenance organization or a maximum of five million dollars ($5,000,000) in aggregate maintained on behalf of health maintenance organizations owned by a common parent corporation, or such sum as may be prescribed by the superintendent.
1978 Comp., § 59A-46-6, enacted by Laws 1993, ch. 266, § 6.
NMSA 1978, § 59A-46-7 Quality assurance program
59A-46-7. Quality assurance program
A. A health maintenance organization shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. Such procedures shall include mechanisms to assure availability, accessibility and continuity of care.
B. A health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and non-institutional settings. The program shall include, at a minimum, the following:
(1) a written statement of goals and objectives that emphasizes improved health status in evaluating the quality of care rendered to enrollees;
(2) a written quality assurance plan that describes the following:
(a) the health maintenance organization's scope and purpose in quality assurance;
(b) the organizational structure responsible for quality assurance activities;
(c) contractual arrangements, where appropriate, for delegation of quality assurance activities;
(d) confidentiality policies and procedures;
(e) a system of ongoing evaluation activities;
(f) a system of focused evaluation activities;
(g) a system for credentialing providers and performing peer review activities; and
(h) duties and responsibilities of the designated physician responsible for the quality assurance activities;
(3) a written statement describing the system of ongoing quality assurance activities, including:
(a) problem assessment, identification, selection and study;
(b) corrective action, monitoring, evaluation and reassessment; and
(c) interpretation and analysis of patterns of care rendered to individual patients by individual providers;
(4) a written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population that identifies method of topic selection, study, data collection, analysis, interpretation and report format; and
(5) written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard services have been provided or services that should have been furnished have not been provided.
C. A health maintenance organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available for examination by the superintendent and by the secretary of health if requested by the superintendent but shall not be disclosed to third parties except as permitted by the provisions of Chapter 59A, Article 46 NMSA 1978.
D. A health maintenance organization shall ensure the use and maintenance of an adequate patient record system that will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees.
E. Except as otherwise restricted or prohibited by state or federal law, enrollee clinical records shall be available to the superintendent or an authorized designee for examination and review to ascertain compliance with this section or as deemed necessary by the superintendent.
F. A health maintenance organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers and appropriate organization staff.
1978 Comp., § 59A-46-7, enacted by Laws 1993, ch. 266, § 7.
NMSA 1978, § 59A-46-8 Requirements for group contract, individual contract and evidence of coverage
59A-46-8. Requirements for group contract, individual contract and evidence of coverage
A. Every group and individual contract holder is entitled to a group or individual contract. The contract shall not contain provisions or statements that are unjust, unfair, inequitable, misleading, deceptive or that encourage misrepresentation as described in Section 59A-16-4 NMSA 1978. The contract shall contain a clear statement of the following:
(1) name and address of the health maintenance organization;
(2) eligibility requirements;
(3) benefits and services within the service area;
(4) emergency care benefits and services;
(5) out-of-area benefits and services, if any;
(6) copayments, deductibles or other out-of-pocket expenses;
(7) limitations and exclusions;
(8) enrollee termination;
(9) enrollee reinstatement, if any;
(10) claims procedures;
(11) enrollee grievance procedures;
(12) continuation of coverage;
(13) conversion;
(14) extension of benefits, if any;
(15) coordination of benefits, if applicable;
(16) subrogation, if any;
(17) description of the service area;
(18) entire contract provision;
(19) term of coverage;
(20) cancellation of group or individual contract holder;
(21) renewal;
(22) reinstatement of group or individual contract holder, if any;
(23) grace period; and
(24) conformity with state law.
B. An evidence of coverage may be filed as part of the group contract to describe the provisions required in Paragraphs (1) through (17) and (20) of Subsection A of this section.
C. In addition to those provisions required in Paragraphs (1) through (24) of Subsection A of this section, an individual contract shall provide for a ten-day period to examine and return the contract and have the premium refunded. If services were received during the ten-day period, and the person returns the contract to receive a refund of the premium paid, he or she must pay for such services.
D. Every subscriber shall receive an evidence of coverage from the group contract holder or the health maintenance organization. The evidence of coverage shall not contain provisions or statements that are unfair, unjust, inequitable, misleading, deceptive or that encourage misrepresentation as described in Section 59A-16-4 NMSA 1978. The evidence of coverage shall contain a clear statement of the provisions required in Paragraphs (1) through (17) and (20) of Subsection A of this section.
E. The superintendent may adopt regulations establishing readability standards for individual contract, group contract and evidence of coverage forms.
F. No group or individual contract, evidence of coverage or amendment thereto shall be delivered or issued for delivery in this state, unless its form has been filed with and approved by the superintendent, subject to Subsections G and H of this section.
G. If an evidence of coverage issued pursuant to and incorporated in a contract issued in this state is intended for delivery in another state and the evidence of coverage has been approved for use in the state in which it is to be delivered, the evidence of coverage need not be submitted to the superintendent for approval.
H. Every form of group or individual contract, evidence of coverage or amendment thereto required to be filed pursuant to the provisions of Subsection F of this section shall be filed with the superintendent not less than thirty days prior to delivery or issue for delivery in this state. At any time during the initial thirty day period, the superintendent may extend the period for review for an additional thirty days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the superintendent has taken no action. The filer must notify the superintendent in writing prior to using a form that is deemed approved.
I. At any time, after thirty days notice and for cause shown, the superintendent may withdraw approval of any form of group or individual contract, evidence of coverage or amendment thereto, effective at the end of the thirty-day notice period.
J. When a filing is disapproved or approval of a form of group or individual contract, evidence of coverage or amendment thereto is withdrawn, the superintendent shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty days of receipt of the notice the health maintenance organization may request a hearing. A hearing shall be conducted within thirty days after the superintendent has received the request for hearing.
K. The superintendent may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
1978 Comp., § 59A-46-8, enacted by Laws 1993, ch. 266, § 8.
NMSA 1978, § 59A-46-9 Annual report
59A-46-9. Annual report
A. Every health maintenance organization shall annually, on or before the first day of March, file a report, verified by at least two principal officers, with the superintendent covering the preceding calendar year.
B. The report shall be on forms prescribed by the superintendent and shall include:
(1) a financial statement of the organization prepared pursuant to forms prescribed by the superintendent, including its balance sheet and receipts and disbursements for the preceding year;
(2) any material changes in the information submitted pursuant to Subsection C of Section 59A-46-3 NMSA 1978;
(3) the number of persons enrolled during the year and the number of enrollees as of the end of the year; and
(4) such other reasonable information materially relating to the performance of the health maintenance organization as is necessary to enable the superintendent to carry out the superintendent's duties under the Insurance Code.
C. In addition, the health maintenance organization shall file by the dates indicated:
(1) on or before March 1, an annual statement in accordance with the requirements of Section 59A-5-29 NMSA 1978 and a risk-based capital report in accordance with the requirements of Section 59A-5A-3 NMSA 1978;
(2) a list of the providers who have executed a contract that complies with Subsection E of Section 59A-46-13 NMSA 1978 on or before March 1; and
(3) a description of the grievance procedures and the total number of grievances handled through such procedures, a compilation of the causes underlying those grievances and a summary of the final disposition of those grievances, on or before March 1.
D. The superintendent may require such additional reports as are deemed necessary and appropriate to enable the superintendent to carry out the superintendent's duties under the Health Maintenance Organization Law.
1978 Comp., § 59A-46-9, enacted by Laws 1993, ch. 266, § 9; 2014, ch. 59, § 51.
NMSA 1978, § 59A-46-10 Information to enrollees or subscribers
59A-46-10. Information to enrollees or subscribers
A. A health maintenance organization shall provide to its subscribers or to its group contract holders for distribution to subscribers a list of providers upon enrollment and re-enrollment.
B. Every health maintenance organization shall notify its subscribers within thirty days of any material change in the operation of the organization that will affect the service to subscribers directly.
C. An enrollee shall be notified in writing by the health maintenance organization of the termination of any designated primary care provider who provided health care services to that enrollee. The health maintenance organization shall provide assistance to the enrollee in transferring to another participating primary care provider.
D. The health maintenance organization shall provide to subscribers information on how services may be obtained, where additional information on access to services may be obtained and a number where the enrollee may contact the health maintenance organization at no cost to the enrollee.
1978 Comp., § 59A-46-10, enacted by Laws 1993, ch. 266, § 10.
NMSA 1978, § 59A-46-11 Grievance procedures
59A-46-11. Grievance procedures
A. Every health maintenance organization shall establish and maintain a grievance procedure that has been approved by the superintendent to provide procedures for the resolution of grievances initiated by enrollees. The health maintenance organization shall maintain records regarding grievances received since the date of its last examination of such grievances.
B. The superintendent or his designee may examine such grievance procedures and records.
1978 Comp., § 59A-46-11, enacted by Laws 1993, ch. 266, § 11.
NMSA 1978, § 59A-46-12 Investments
59A-46-12. Investments
With the exception of investments made in accordance with Paragraph (1) of Subsection A of Section 59A-46-5 NMSA 1978, the funds of a health maintenance organization shall be invested only in accordance with Chapter 59A, Article 9 NMSA 1978 and such regulations as the superintendent may promulgate consistent with that article and the provisions of the Health Maintenance Organization Law.
1978 Comp., § 59A-46-12, enacted by Laws 1993, ch. 266, § 12.
NMSA 1978, § 59A-46-13 Protection against insolvency
59A-46-13. Protection against insolvency
A. Health maintenance organizations shall be subject to the following net worth requirements:
(1) before any certificate of authority is issued to a health maintenance organization, it shall have an initial net worth of one million five hundred thousand dollars ($1,500,000) and shall thereafter maintain the minimum net worth required under Paragraph (2) of this subsection;
(2) except as provided in Paragraphs (3) and (4) of this subsection, every health maintenance organization shall maintain a minimum net worth equal to the greater of:
(a) one million dollars ($1,000,000);
(b) two percent of annual premium revenues as reported on the most recent annual financial statement filed with the superintendent on the first one hundred fifty million dollars ($150,000,000) of premium revenues and one percent of annual premium on the premium in excess of one hundred fifty million dollars ($150,000,000);
(c) an amount equal to the sum of three months uncovered health care expenditures as reported on the most recent financial statement filed with the superintendent; or
(d) an amount equal to the sum of: 1) eight percent of annual health care expenditures for enrollees under prepaid contracts except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the superintendent; and 2) four percent of annual hospital expenditures for enrollees under prepaid contracts paid on a capitated basis and a managed hospital payment basis as reported on the most recent financial statement filed with the superintendent;
(3) a health maintenance organization licensed before the effective date of Chapter 59A, Article 46 NMSA 1978 shall maintain a minimum net worth of:
(a) twenty-five percent of the amount required by Paragraph (2) of this subsection by December 31, 1994;
(b) fifty percent of the amount required by Paragraph (2) of this subsection by December 31, 1995;
(c) seventy-five percent of the amount required by Paragraph (2) of this subsection by December 31, 1996; and
(d) one hundred percent of the amount required by Paragraph (2) of this subsection by December 31, 1997; and
(4) in determining net worth for the purposes of Paragraph (3) of this subsection:
(a) no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the superintendent and any interest obligation relating to the repayment of any subordinated debt must be similarly subordinated;
(b) the interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses;
(c) any debt incurred by a surplus note meeting the requirements of Section 59A-34-23 NMSA 1978, and otherwise acceptable to the superintendent, shall not be considered a liability and shall be recorded as equity; and
(d) preferred stock shall not be considered debt.
B. Health maintenance organizations shall be subject to the following deposit requirements:
(1) unless otherwise provided below, each health maintenance organization shall deposit with the superintendent or, at the discretion of the superintendent, with any organization or trustee acceptable to him through which a custodial or controlled account is utilized, cash, securities or any combination of these or other measures that are acceptable to him that at all times shall have a value of not less than three hundred thousand dollars ($300,000);
(2) a health maintenance organization that is in operation on the effective date of this section shall make a deposit equal to one hundred fifty thousand dollars ($150,000) and, in the second year, the amount of the additional deposit for a health maintenance organization that is in operation on the effective date of this section shall be equal to one hundred fifty thousand dollars ($150,000), for a total of three hundred thousand dollars ($300,000);
(3) the deposit shall be an admitted asset of the health maintenance organization in the determination of net worth;
(4) all income from deposits shall be an asset of the organization, but a health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities or any combination of these or other assets of equal amount and value;
(5) any securities deposited pursuant to the provisions of this subsection shall be approved by the superintendent before being deposited or substituted;
(6) the deposit shall be used to protect the interests of the health maintenance organization's enrollees and to assure continuation of health care services to enrollees of a health maintenance organization that is in rehabilitation or conservation;
(7) the superintendent may use a deposit made pursuant to the provisions of this subsection for administrative costs directly attributable to a receivership or liquidation, and if the health maintenance organization is placed in receivership or liquidation, the deposit shall be an asset subject to the provisions of the applicable liquidation law; and
(8) the superintendent may reduce or eliminate the deposit requirement if the health maintenance organization deposits with the state treasurer, insurance superintendent or other official body of the state or jurisdiction of domicile for the protection of all subscribers and enrollees, wherever located, of such health maintenance organization, cash, acceptable securities or surety, and delivers to the superintendent a certificate to such effect, duly authenticated by the appropriate state official holding the deposit.
C. Every health maintenance organization shall include when determining liabilities an amount estimated in the aggregate to provide for:
(1) any unearned premium;
(2) the payment of all claims for health care expenditures that have been incurred, whether reported or unreported, which are unpaid and for which the health maintenance organization is or may be liable;
(3) the expense of adjustment or settlement of the claims described in Paragraph (2) of this subsection; and
(4) contract liabilities for continuation of coverage or conversion rights not covered by future premiums or hold harmless agreements.
D. Liabilities described in Subsection C of this section shall be computed in accordance with regulations adopted by the superintendent upon reasonable consideration of the ascertained experience and character of the health maintenance organization.
E. Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization. In the event that the participating provider contract has not been reduced to writing or the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization. No participating provider or agent, trustee or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.
F. The superintendent shall require that each health maintenance organization have a plan for handling insolvency that allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. In considering the plan, the superintendent may require:
(1) insurance to cover the expenses to be paid for continued benefits after an insolvency;
(2) provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization's insolvency for which premium payment has been made and until the enrollees' discharge from inpatient facilities;
(3) insolvency reserves;
(4) acceptable letters of credit; or
(5) any other arrangements to assure that benefits are continued as specified above.
G. An agreement to provide health care services between a provider and a health maintenance organization shall require that if the provider terminates the agreement, the provider shall give the organization at least sixty days' advance notice of termination.
1978 Comp., § 59A-46-13, enacted by Laws 1993, ch. 266, § 13.
NMSA 1978, § 59A-46-14 Uncovered expenditures insolvency deposit
59A-46-14. Uncovered expenditures insolvency deposit
A. If at any time uncovered expenditures exceed ten percent of total health care expenditures, a health maintenance organization shall place an uncovered expenditures insolvency deposit with the superintendent, with any organization or trustee acceptable to the superintendent through which a custodial or controlled account is maintained, cash or securities that are acceptable to the superintendent. Such deposit shall at all times have a fair market value in an amount of one hundred twenty percent of the health maintenance organization's outstanding liability for uncovered expenditures for enrollees in this state, including incurred but not reported claims, and shall be calculated as of the first day of the month and maintained for the remainder of the month. If a health maintenance organization is not otherwise required to file a quarterly report, it shall file a report within forty-five days of the end of the calendar quarter with information sufficient to demonstrate compliance with this subsection.
B. The deposit required under Subsection A of this section is in addition to the deposit required under Section 59A-46-13 NMSA 1978 and is an admitted asset of the health maintenance organization in the determination of net worth. All income from such deposits or trust accounts shall be assets of the health maintenance organization and may be withdrawn from such deposit or account quarterly with the approval of the superintendent.
C. A health maintenance organization that has made a deposit may withdraw that deposit or any part of the deposit if a substitute deposit of cash or securities of equal amount and value is made, the fair market value of the deposit exceeds the amount of the required deposit, or the required deposit under Subsection A of this section is reduced or eliminated. Deposits, substitutions or withdrawals may be made only with the prior written approval of the superintendent.
D. The deposit required under Subsection A of this section is in trust and may be used only as provided under this section. The superintendent may use the deposit of an insolvent health maintenance organization for administrative costs associated with administering the deposit and payment of claims of enrollees of this state for uncovered expenditures in this state. Claims for uncovered expenditures shall be paid on a pro rata basis based on assets available to pay such ultimate liability for incurred expenditures. Partial distribution may be made pending final distribution. Any amount of the deposit remaining shall be paid into the liquidation or receivership of the health maintenance organization.
E. The superintendent may by regulation prescribe the time, manner and form for filing claims under Subsection D of this section.
F. The superintendent may by regulation or order require health maintenance organizations to file annual, quarterly or more frequent reports as he deems necessary to demonstrate compliance with this section. The superintendent may require that the reports include liability for uncovered expenditures as well as an audit opinion.
1978 Comp., § 59A-46-14, enacted by Laws 1993, ch. 266, § 14.
NMSA 1978, § 59A-46-16 Filing requirements for rating information
59A-46-16. Filing requirements for rating information
A. No premium rate may be used until either a schedule of premium rates or methodology for determining premium rates has been filed with and approved by the superintendent. At the time the health maintenance organization files the rate with the superintendent it shall also file a schedule of benefits to which the rate applies.
B. Either a specific schedule of premium rates, or a methodology for determining premium rates, shall be established in accordance with actuarial principles for various categories of enrollees; provided that the premium applicable to an enrollee shall not be individually determined based on the status of the enrollee's health. A certification by a qualified actuary or other qualified person acceptable to the superintendent as to the appropriateness of the rates or of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
C. The superintendent may disapprove any such rates, or methodology for determining rates, found by him to be excessive, inadequate or unfairly discriminatory, considering the benefits to be provided. If the superintendent disapproves such filing, he shall notify the health maintenance organization, specifying the reasons for his disapproval. A hearing shall be conducted within thirty days after a request in writing by the person filing. The schedule or methodology shall be deemed approved if the superintendent does not disapprove the filing within thirty days, but the superintendent in his sole discretion may postpone taking action for an additional thirty days as necessary for proper consideration of the filing.
1978 Comp., § 59A-46-16, enacted by Laws 1993, ch. 266, § 16.
NMSA 1978, § 59A-46-17 Regulation of health maintenance organization insurance producers
59A-46-17. Regulation of health maintenance organization insurance producers
A. Requirements and procedures for licensing of health maintenance organization insurance producers shall be governed by the provisions of Chapter 59A, Articles 11 and 12 NMSA 1978 and any regulations adopted by the superintendent pertaining to those articles.
B. None of the following shall be required to hold a health maintenance organization insurance producer license:
(1) any regular salaried officer or employee of a health maintenance organization who devotes substantially all of that person's time to activities other than the taking or transmitting of applications or membership fees or premiums for health maintenance organization membership or who receives no commission or other compensation directly dependent upon the business obtained and who does not solicit or accept from the public applications for health maintenance organization membership;
(2) employers or their officers or employees or the trustees of any employee benefit plan to the extent that such employers, officers, employees or trustees are engaged in the administration or operation of any program of employee benefits involving the use of health maintenance organization memberships, if those employers, officers, employees or trustees are not compensated directly or indirectly by the health maintenance organization issuing the health maintenance organization memberships;
(3) banks or their officers and employees to the extent that such banks, officers and employees collect and remit charges by charging same against accounts of depositors on the orders of such depositors; or
(4) any person or the employee of any person who has contracted to provide administrative, management or health care services to a health maintenance organization and who is compensated for those services by the payment of an amount calculated as a percentage of the revenues, net income or profit of the health maintenance organization, if that method of compensation is the sole basis for subjecting that person or the employee of the person to the provisions of the Health Maintenance Organization Law.
C. The superintendent may by rule exempt certain classes of persons from the requirement of obtaining a license if:
(1) the functions they perform do not require special competence, trustworthiness or the regulatory surveillance made possible by licensing; or
(2) other existing safeguards make regulation unnecessary.
1978 Comp., § 59A-46-17, enacted by Laws 1993, ch. 266, § 17; 2016, ch. 89, § 66.
NMSA 1978, § 59A-46-18 Powers of insurers
59A-46-18. Powers of insurers
A. An authorized insurer may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of the Health Maintenance Organization Law. Notwithstanding any other law that may be inconsistent with the cited law, any two or more such insurance companies, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.
B. An authorized insurer may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. Among other things, under such contracts the insurer may make benefit payments to health maintenance organizations for health care services rendered by providers.
1978 Comp., § 59A-46-18, enacted by Laws 1993, ch. 266, § 18.
NMSA 1978, § 59A-46-19 Examinations
59A-46-19. Examinations
A. The superintendent may make an examination of the affairs of any health maintenance organization and providers with whom the health maintenance organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state, but not less frequently than once every five years.
B. The superintendent may make or request the secretary of health to make an examination concerning the quality assurance program of the health maintenance organization and of any providers with whom the health maintenance organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state.
C. Every health maintenance organization and provider shall submit its books and records for examinations and in every way facilitate the completion of the examination. Medical records of individuals and contract providers shall not be subject to examination. For the purpose of examinations, the superintendent and the secretary of health may administer oaths to and examine the officers and agents of the health maintenance organization and the principals of the providers concerning their business.
D. The expenses of examinations under this section shall be assessed against the health maintenance organization being examined and remitted to the superintendent.
E. In lieu of examination, the superintendent may accept the report of an examination made by the superintendent or secretary of health of another state.
F. Examination procedures shall be governed by the applicable provisions of Chapter 59A, Article 4 NMSA 1978.
1978 Comp., § 59A-46-19, enacted by Laws 1993, ch. 266, § 19; 2025, ch. 108, § 6.
NMSA 1978, § 59A-46-20 Suspension or revocation of certificate of authority
59A-46-20. Suspension or revocation of certificate of authority
A. Any certificate of authority issued under the provisions of the Health Maintenance Organization Law may be suspended or revoked, and any application for a certificate of authority may be denied if the superintendent finds that:
(1) the health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under Section 59A-46-3 NMSA 1978, unless amendments to such submissions have been filed with and approved by the superintendent;
(2) the health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services that does not comply with the requirements of Sections 59A-46-8 and 59A-46-16 NMSA 1978;
(3) the health maintenance organization does not provide or arrange for basic health care services;
(4) the secretary of health has certified to the superintendent that:
(a) the health maintenance organization does not meet the requirements of Paragraph (2) of Subsection A of Section 59A-46-4 NMSA 1978; or
(b) the health maintenance organization is unable to fulfill its obligations to furnish health care services;
(5) the health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(6) the health maintenance organization has failed to correct, within the time prescribed by Subsection C of this section, any deficiency occurring due to the health maintenance organization's prescribed minimum net worth being impaired;
(7) the health maintenance organization has failed to implement the grievance procedures required by Section 59A-46-11 NMSA 1978 in a reasonable manner to resolve valid complaints;
(8) the health maintenance organization, or any person on its behalf, has engaged in any practice that under Chapter 59A, Article 16 NMSA 1978 is defined or prohibited as, or determined to be, an unfair method of competition, or an unfair or deceptive act or practice, or fraudulent;
(9) the continued operation of the health maintenance organization would be hazardous to its enrollees; or
(10) the health maintenance organization has otherwise failed substantially to comply with the provisions of the Health Maintenance Organization Law.
B. In addition to or in lieu of suspension or revocation of a certificate of authority pursuant to this section, the applicant or health maintenance organization may be subjected to an administrative penalty of up to five thousand dollars ($5,000) for each cause for suspension or revocation, but if the violation is willful or intentional, the administrative penalty may be up to ten thousand dollars ($10,000).
C. Whenever the superintendent finds that the net worth maintained by any health maintenance organization subject to the provisions of the Health Maintenance Organization Law is less than the minimum net worth required to be maintained pursuant to the provisions of Section 59A-46-13 NMSA 1978, he shall give written notice to the health maintenance organization of the amount of the deficiency and require the health maintenance organization to:
(1) file with the superintendent a plan for correction of the deficiency acceptable to the superintendent; and
(2) correct the deficiency within a reasonable time, not to exceed sixty days, unless an extension of time, not to exceed sixty additional days, is granted by the superintendent.
D. A deficiency found to exist by the superintendent pursuant to the provisions of Subsection C of this section shall be deemed an impairment, and failure to correct the impairment in the prescribed time shall be grounds for suspension or revocation of the certificate of authority of the health maintenance organization or for placing it in conservation, rehabilitation or liquidation.
E. Unless allowed by the superintendent no health maintenance organization or person acting on its behalf may, directly or indirectly, renew, issue or deliver any certificate, agreement or contract of coverage in this state, for which a premium is charged or collected, when the health maintenance organization writing such coverage is impaired, and the fact of such impairment is known to the health maintenance organization or to such person. However, the existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement or contract when the enrollee exercises an option granted under the plan to obtain a new, renewed or converted coverage.
F. A certificate of authority shall not be suspended or revoked or an application for a certificate of authority denied or an administrative penalty imposed unless:
(1) the suspension, revocation, denial or imposition is by written order and is sent to the health maintenance organization or applicant by certified or registered mail; and
(2) the written order states the grounds, charges or conduct on which the suspension, revocation, denial or imposition is based.
G. The health maintenance organization or applicant may in writing request a hearing within thirty days from the date of mailing of an order suspending or revoking a certificate of authority, denying an application or imposing an administrative penalty. If no written request is made, such order shall be final upon the expiration of the thirty days.
H. If the health maintenance organization or applicant requests a hearing pursuant to the provisions of Subsection G of this section, the superintendent shall issue a written notice of hearing and send it to the health maintenance organization or applicant by certified or registered mail stating:
(1) a specific time for the hearing, which may not be less than twenty nor more than thirty days after mailing of the notice of hearing; and
(2) a specific place for the hearing, which may be either in Santa Fe county or in the county where the health maintenance organization's or applicant's principal place of business is located.
I. After a hearing held pursuant to the provisions of Subsection H of this section or upon failure of the health maintenance organization to appear at the hearing, the superintendent shall take whatever action he deems necessary based on written findings and shall mail his decision to the health maintenance organization or applicant.
J. The provisions of Chapter 59A, Article 4 NMSA 1978 shall apply to proceedings under this section to the extent they are not in conflict with Subsection H of this section.
K. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.
L. When the certificate of authority of a health maintenance organization is revoked, that organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The superintendent may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.
1978 Comp., § 59A-46-20, enacted by Laws 1993, ch. 266, § 20.
NMSA 1978, § 59A-46-21 Rehabilitation, liquidation or conservation of health maintenance organizations
59A-46-21. Rehabilitation, liquidation or conservation of health maintenance organizations
A. Any rehabilitation, liquidation or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation or conservation of an insurer and shall be conducted under the supervision of the superintendent pursuant to the law governing the rehabilitation, liquidation or conservation of insurers. The superintendent may apply for an order directing him to rehabilitate, liquidate or conserve a health maintenance organization upon any one or more grounds set out in Chapter 59A, Article 41 NMSA 1978 or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
B. For purpose of determining the priority of distribution of general assets, claims of enrollees and enrollees' beneficiaries shall have the same priority as established by Subsection C of Section 59A-41-44 NMSA 1978 for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets.
C. Any provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees' beneficiaries as described in Subsection B of this section and immediately preceding the priority of distribution described in Subsection D of Section 59A-41-44 NMSA 1978.
1978 Comp., § 59A-46-21, enacted by Laws 1993, ch. 266, § 21.
NMSA 1978, § 59A-46-22 Summary orders and supervision
59A-46-22. Summary orders and supervision
A. Whenever the superintendent determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors or the general public, or that it has violated any provision of the Health Maintenance Organization Law, he may, after notice and hearing, order the health maintenance organization to take such action as may be reasonably necessary to rectify such condition or violation, including but not limited to one or more of the following:
(1) reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the superintendent;
(2) reduce the volume of new business being accepted;
(3) reduce expenses by specified methods;
(4) suspend or limit the writing of new business for a period of time;
(5) increase the health maintenance organization's capital and surplus by contribution; or
(6) take such other steps as the superintendent may deem appropriate under the circumstances, including suspension or revocation of the certificate or authority or assessment of administrative penalties as provided in Section 59A-46-20 NMSA 1978.
B. For purposes of this section, the violation by a health maintenance organization of any law of this state to which such health maintenance organization is subject shall be deemed a violation of the provisions of the Health Maintenance Organization Law.
C. The superintendent is authorized to make rules and regulations setting uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors or the general public and setting standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purposes expressed in Subsection A of this section.
D. The remedies and measures available to the superintendent under this section shall be in addition to, and not in lieu of, the remedies and measures available to the superintendent under the provisions of Chapter 59A, Article 41 NMSA 1978.
Laws 1993, ch. 266, § 22.
NMSA 1978, § 59A-46-23 Regulations
59A-46-23. Regulations
The superintendent may, after notice and hearing, adopt and promulgate reasonable rules and regulations as are necessary or proper to carry out the provisions of the Health Maintenance Organization Law.
1978 Comp., § 59A-46-23, enacted by Laws 1993, ch. 266, § 23.
NMSA 1978, § 59A-46-24 Fees
59A-46-24. Fees
Every health maintenance organization subject to the provisions of the Health Maintenance Organization Law shall pay to the superintendent all applicable fees specified in Section 59A-6-1 NMSA 1978.
1978 Comp., § 59A-46-24, enacted by Laws 1993, ch. 266, § 24.
NMSA 1978, § 59A-46-25 Penalties and enforcement
59A-46-25. Penalties and enforcement
A. The superintendent may, in lieu of suspension or revocation of a certificate of authority pursuant to the provisions of Section 59A-46-20 NMSA 1978, levy an administrative penalty in an amount up to five thousand dollars ($5,000), except that if the violation is willful or intentional, the administrative penalty may be up to ten thousand dollars ($10,000). The superintendent may augment this penalty by an amount equal to the sum that he calculates to be the damages suffered by enrollees or other members of the public.
B. If the superintendent shall for any reason have cause to believe that any violation of the provisions of the Health Maintenance Organization Law has occurred or is threatened, the superintendent may give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in such suspected violation, to arrange a conference with the alleged violators or their authorized representatives for the purpose of attempting to ascertain the facts relating to such suspected violation and, in the event it appears that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing such violation.
C. A conference arranged under the provisions of Subsection B of this section shall not be governed by any formal procedural requirements, and may be conducted in such manner as the superintendent may deem appropriate under the circumstances.
D. The superintendent may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of the Health Maintenance Organization Law. Within thirty days after service of the cease and desist order, the respondent may request a hearing on the question of whether acts or practices in violation of that law have occurred. Such hearings shall be governed by the provisions of Chapter 59A, Article 4 NMSA 1978.
E. In the case of any violation of the provisions of the Health Maintenance Organization Law, if the superintendent elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to Subsection D of this section, the superintendent may institute a proceeding to obtain injunctive or other appropriate relief in the Santa Fe county district court.
F. Notwithstanding any other provisions of the Health Maintenance Organization Law, if a health maintenance organization fails to comply with the net worth requirement of that law, the superintendent is authorized to take appropriate action to assure that the continued operation of the health maintenance organization will not be hazardous to its enrollees.
1978 Comp., § 59A-46-25, enacted by Laws 1993, ch. 266, § 25.
NMSA 1978, § 59A-46-26 Filings and reports as public documents
59A-46-26. Filings and reports as public documents
All applications, filings and reports required under the Health Maintenance Organization Law shall be treated as public documents, except those that are trade secrets or privileged or confidential quality assurance, commercial or financial information, other than any annual financial statement that may be required under Section 59A-46-9 NMSA 1978.
1978 Comp., § 59A-46-26, enacted by Laws 1993, ch. 266, § 26.
NMSA 1978, § 59A-46-26.1 Employer utilization and loss experience availability
59A-46-26.1. Employer utilization and loss experience availability
Employer claims information, including utilization and loss experience under health insurance provided under Chapter 59A, Article 46 NMSA 1978 shall be made available by the carrier only upon the written request of and to employers of enrollees with such coverage within thirty days of an employer's written request for such information to the carrier, provided the employer's coverage extends to no less than twenty-five individual enrollees, regardless of whether family coverage is included. Each carrier shall provide to the employer claims information that provides sufficient detail, subject to state and federal privacy laws, to enable the employer to obtain and compare rates from multiple carriers or establish a plan of self-insurance.
Laws 2003, ch. 252, § 4; 2007, ch. 53, § 2.
NMSA 1978, § 59A-46-27 Confidentiality of medical information and limitation of liability
59A-46-27. Confidentiality of medical information and limitation of liability
A. Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from such person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except:
(1) to the extent that it may be necessary to carry out the purposes of the Health Maintenance Organization Law;
(2) upon the express consent of the enrollee or applicant;
(3) pursuant to statute or court order for the production of evidence or the discovery thereof; or
(4) in the event of claim or litigation between such person and the health maintenance organization in which such data or information is pertinent.
B. A health maintenance organization shall be entitled to claim any statutory privileges against disclosure of information described in Subsection A of this section that the provider who furnished the information to the health maintenance organization is entitled to claim.
C. A person who, in good faith and without malice, takes any action or makes any decision or recommendation as a member, agent or employee of a health care review committee or who furnishes any records, information or assistance to such a committee shall not be subject to liability for civil damages or any legal action in consequence of such action, nor shall the health maintenance organization that established such committee or the officers, directors, employees or agents of such health maintenance organization be liable for the activities of any such person. The provisions of this subsection do not relieve any person of liability arising from treatment of a patient.
D. The information considered by a health care review committee and the records of their actions and proceedings shall be confidential and not subject to subpoena or order to produce except in proceedings before the appropriate state licensing or certifying agency, or in an appeal, if permitted, from the committee's findings or recommendations. No member of a health care review committee, or officer, director or other member of a health maintenance organization or its staff engaged in assisting such committee, or any person assisting or furnishing information to such committee may be subpoenaed to testify in any judicial or quasi-judicial proceeding if such subpoena is based solely on such activities.
E. Information considered by a health care review committee and the records of its actions and proceedings that are used pursuant to Subsection D of this section by a state licensing or certifying agency or in an appeal shall be kept confidential and shall be subject to the same provision concerning discovery and use in legal actions as are the original information and records in the possession and control of a health care review committee.
F. To fulfill its obligations under Section 59A-46-7 NMSA 1978, the health maintenance organization shall have access to treatment records and other information pertaining to the diagnosis, treatment or health status of any enrollee.
1978 Comp., § 59A-46-27, enacted by Laws 1993, ch. 266, § 27.
NMSA 1978, § 59A-46-28 Authority to contract
59A-46-28. Authority to contract
The secretary of health, in carrying out his obligations as requested by the superintendent under the provisions of the Health Maintenance Organization Law, may contract with qualified persons to make recommendations concerning the determinations required to be made by him, which recommendations may be accepted in full or in part or rejected entirely.
1978 Comp., § 59A-46-28, enacted by Laws 1993, ch. 266, § 28.
NMSA 1978, § 59A-46-29 Health maintenance organizations; contract or certificate provisions relating to individuals who are eligible for medical benefits under the medicaid program
59A-46-29. Health maintenance organizations; contract or certificate provisions relating to individuals who are eligible for medical benefits under the medicaid program
A. Each individual or group contract or certificate that is delivered, issued for delivery or renewed in this state shall include provisions that require any indemnity benefits payable by a health maintenance organization on behalf of an enrollee under the contract or certificate to be paid to the human services department [health care authority department] when:
(1) the human services department [health care authority department] has paid or is paying benefits on behalf of the enrollee under the state's medicaid program pursuant to Title XIX of the federal Social Security Act, 42 U.S.C. 1396, et seq.;
(2) payment for the services in question has been made by the human services department [health care authority department] to the medicaid provider; and
(3) the health maintenance organization is notified that the enrollee receives benefits under the medicaid program and that any indemnity benefits payable by the health maintenance organization must be paid directly to the human services department [health care authority department].
B. The notice required under Paragraph (3) of Subsection A of this section may be accomplished through an attachment to the claim by the human services department [health care authority department] for any indemnity benefits payable by the health maintenance organization when the claim is first submitted by the human services department [health care authority department] to the health maintenance organization.
C. Notwithstanding any other provisions of law, checks in payment for claims for any indemnity benefits payable by a health maintenance organization pursuant to any individual or group contract or certificate for health care services provided to persons who are also eligible for benefits under the medicaid program and provided by medical providers not contracting with the health maintenance organization shall be made payable to the provider. The health maintenance organization may be notified that the enrollee is eligible for medicaid benefits through an attachment to the claim by the provider for health maintenance organization benefits when the claim is first submitted by the provider to the health maintenance organization.
D. No health maintenance organization group or individual contract or certificate delivered, issued for delivery or renewed in this state on or after the effective date of this section shall contain any provision denying or limiting health maintenance organization benefits because services are rendered to an enrollee who is eligible for or who has received medical assistance under the medicaid program of this state.
E. To the extent that payment for covered expenses has been made pursuant to the state medicaid program for health care items or services furnished to an individual, in any case where a health maintenance organization has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by the health maintenance organization for those health care items or services.
1978 Comp., § 59A-46-34, enacted by Laws 1989, ch. 183, § 6; recompiled as 1978 Comp., § 59A-46-29 by Laws 1993, ch. 266, § 31; 1994, ch. 64, § 8.
NMSA 1978, § 59A-46-30 Statutory construction and relationship to other laws
59A-46-30. Statutory construction and relationship to other laws
A. The provisions of the Insurance Code [Chapter 59A NMSA 1978] other than Chapter 59A, Article 46 NMSA 1978 shall not apply to health maintenance organizations except as expressly provided in the Insurance Code and that article. To the extent reasonable and not inconsistent with the provisions of that article, the following articles and provisions of the Insurance Code shall also apply to health maintenance organizations and their promoters, sponsors, directors, officers, employees, agents, solicitors and other representatives. For the purposes of such applicability, a health maintenance organization may therein be referred to as an "insurer":
(1) Chapter 59A, Article 1 NMSA 1978;
(2) Chapter 59A, Article 2 NMSA 1978;
(3) Chapter 59A, Article 4 NMSA 1978;
(4) Subsection C of Section 59A-5-22 NMSA 1978;
(5) Sections 59A-6-2 through 59A-6-4 and 59A-6-6 NMSA 1978;
(6) Chapter 59A, Article 8 NMSA 1978;
(7) Chapter 59A, Article 10 NMSA 1978;
(8) Chapter 59A, Article 16 NMSA 1978;
(9) the Domestic Abuse Insurance Protection Act [59A-16B-1 to 59A-16B-10 NMSA 1978];
(10) the Insurance Fraud Act [Chapter 59A, Article 16C NMSA 1978];
(11) Chapter 59A, Article 18 NMSA 1978;
(12) the Policy Language Simplification Law [59A-19-1 to 59A-19-7 NMSA 1978];
(13) Section 59A-22-14 NMSA 1978;
(14) the Health Insurance Portability Act [Chapter 59A, Article 23E NMSA 1978];
(15) Sections 59A-34-2, 59A-34-7 through 59A-34-13, 59A-34-17, 59A-34-23, 59A-34-33, 59A-34-36, 59A-34-37, 59A-34-40 through 59A-34-42 and 59A-34-44 through 59A-34-46 NMSA 1978;
(16) the Insurance Holding Company Law [Chapter 59A, Article 37 NMSA 1978];
(17) the Patient Protection Act [Chapter 59A, Article 57 NMSA 1978]; and
(18) the Surprise Billing Protection Act [59A-57A-1 to 59A-57A-13 NMSA 1978].
B. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed as violating any provision of law relating to solicitation or advertising by health professionals, but health professionals shall be individually subject to the laws, rules and ethical provisions governing their individual professions.
C. Any health maintenance organization authorized under the provisions of the Health Maintenance Organization Law shall not be deemed to be practicing medicine and shall be exempt from the provisions of laws relating to the practice of medicine.
1978 Comp., § 59A-46-30, enacted by Laws 1993, ch. 266, § 29; 1997, ch. 248, § 2; 1998, ch. 107, § 13; 1999, ch. 289, § 34; 2001, ch. 297, § 5; 2009, ch. 212, § 4; 2021, ch. 108, § 26.
NMSA 1978, § 59A-46-31 Coordination of benefits
59A-46-31. Coordination of benefits
A. Health maintenance organizations are permitted, but not required, to adopt coordination of benefits provisions to avoid overinsurance and to provide for the orderly payment of claims when a person is covered by two or more group health insurance or health care plans.
B. If health maintenance organizations adopt coordination of benefits, the provisions shall be consistent with the coordination of benefits provisions that are in general use in the state for coordinating coverage between two or more group health insurance or health care plans.
C. To the extent necessary for health maintenance organizations to meet their obligations as secondary carriers under the regulations established by the superintendent, health maintenance organizations shall make payments for services that are:
(1) received from non-participating providers;
(2) provided outside their service areas; or
(3) not covered under the terms of their group contracts or evidence of coverage.
1978 Comp., § 59A-46-31, enacted by Laws 1993, ch. 266, § 30.
NMSA 1978, § 59A-46-32 Continuation of coverage and conversion rights; health care plans
59A-46-32. Continuation of coverage and conversion rights; health care plans
A. Every individual or group contract entered into by a health maintenance organization and that is delivered, issued for delivery or renewed in this state on or after January 1, 1985 shall provide covered family members of subscribers the right to continue such coverage through a converted or separate contract upon the death of the subscriber or upon the divorce, annulment or dissolution of marriage or legal separation of the spouse from the subscriber. Where a continuation of coverage or conversion is made in the name of the spouse of the subscriber, such coverage may, at the option of the spouse, include coverage to dependent children for whom the spouse has responsibility for care and support.
B. The right to a continuation of coverage or conversion pursuant to this section shall not exist with respect to any covered family member of a subscriber in the event the coverage terminates for nonpayment of premium, nonrenewal of the contract or the expiration of the term for which the contract is issued. With respect to any covered family member who is eligible for medicare or any other similar federal or state health insurance program, the right to a continuation of coverage or conversion shall be limited to coverage under a medicare supplement insurance contract as defined by the rules and regulations adopted by the superintendent of insurance.
C. Coverage continued through the issuance of a converted or separate contract shall be provided at a reasonable, nondiscriminatory rate to the insured and shall consist of a form of coverage then being offered by the health maintenance organization as a conversion contract. Continued and converted coverages shall contain renewal provisions that are not less favorable to the subscriber than those contained in the contract from which the conversion is made, except that the person who exercises the right of conversion is entitled only to have included a right to coverage under a medicare supplement insurance contract, as defined by the rules and regulations adopted by the superintendent of insurance, after the attainment of the age of eligibility for medicare or any other similar federal or state health insurance program.
D. At the time of inception of coverage, the health maintenance organization shall provide each covered family member eighteen years of age or older a statement setting forth in summary form the continuation of coverage and conversion provisions of the subscriber's contract.
E. The eligible covered family member exercising the continuation or conversion right must notify the health maintenance organization and make payment of the applicable premium within thirty days following the date such coverage otherwise terminates as specified in the contract from which continuation or conversion is being exercised.
F. Coverage shall be provided through continuation or conversion without additional evidence of insurability and shall not impose any preexisting condition, limitations or other contractual time limitations.
G. Any probationary or waiting period set forth in the converted or separate contract is deemed to commence on the effective date of the applicant's coverage under the original contract.
Laws 1984, ch. 127, § 876.1; 1978 Comp., § 59A-46-30, recompiled as 1978 Comp., § 59A-46-32 by Laws 1993, ch. 266, § 31; 2019, ch. 259, § 18.
NMSA 1978, § 59A-46-33 Governing body
59A-46-33. Governing body
The governing body of any health maintenance organization may include providers or other individuals, or both. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions or through the use of other mechanisms.
Laws 1984, ch. 127, § 853; 1978 Comp., § 59A-46-6, recompiled as 1978 Comp., § 59A-46-33 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-34 Prohibited practices
59A-46-34. Prohibited practices
A. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this article:
(1) a statement or item of information is deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in a health maintenance organization;
(2) a statement or item of information is deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health maintenance organization, if such benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and
(3) an evidence of coverage is deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care coverage and evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health maintenance organization issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.
B. An enrollee may not be canceled or nonrenewed on the basis of the status of his health.
C. No health maintenance organization, unless licensed as an insurer, may use in its name, contracts or literature any of the words "insurance," "casualty," "surety," "mutual" or any other words descriptive of the insurance, casualty or surety business if such words are used in a manner to imply that such coverages are being illegally offered by the health maintenance organization or if deceptively similar to the name or description of any insurance or surety corporation doing business in the state.
D. Any person not in possession of a valid certificate of authority issued pursuant to this article shall not use the phrase "health maintenance organization" or "HMO" in the course of operation.
Laws 1984, ch. 127, § 860; 1978 Comp., § 59A-46-13, recompiled as 1978 Comp., § 59A-46-34 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-35 Provider discrimination prohibited
59A-46-35. Provider discrimination prohibited
No class of licensed individual providers willing to meet the terms and conditions offered by a health maintenance organization shall be excluded from a health maintenance organization. For purposes of this section, "providers" means those persons licensed pursuant to:
A. the Optometry Act [Chapter 61, Article 2 NMSA 1978];
B. Section 61-3-23.2 NMSA 1978;
C. the Chiropractic Physician Practice Act [Chapter 61, Article 4 NMSA 1978];
D. the Dental Health Care Act [Chapter 61, Article 5A NMSA 1978];
E. the Medical Practice Act [Chapter 61, Article 6 NMSA 1978];
F. the Podiatry Act [Chapter 61, Article 8 NMSA 1978];
G. the Professional Psychologist Act [Chapter 61, Article 9 NMSA 1978];
H. Chapter 61, Article 10 NMSA 1978; or
I. the Pharmacy Act [Chapter 61, Article 11 NMSA 1978].
1978 Comp., § 59A-46-32, enacted by Laws 1987, ch. 335, § 1; 1989, ch. 55, § 1; recompiled as 1978 Comp., § 59A-46-35 by Laws 1993, ch. 266, § 31; 1998, ch. 39, § 1; 2003, ch. 343, § 3.
NMSA 1978, § 59A-46-36 Doctor of oriental medicine; discrimination prohibited
59A-46-36. Doctor of oriental medicine; discrimination prohibited
Doctors of oriental medicine as a class of licensed providers willing to meet the terms and conditions offered by a health maintenance organization shall not be excluded from a health maintenance organization and shall not be discriminated against relative to other classes of licensed providers regarding services provided within their scope of practice that are in compliance with nationally recognized coding systems. Health maintenance organizations may determine the specific procedure codes that a doctor of oriental medicine is contracted to provide. Health maintenance organizations may choose to contract a doctor of oriental medicine as a primary care provider.
Laws 1989, ch. 96, § 2; 1993, ch. 158, § 4; 1978 Comp., § 59A-46-32.1, recompiled as 1978 Comp., § 59A-46-36 by Laws 1993, ch. 266, § 31; 2003, ch. 96, § 1.
NMSA 1978, § 59A-46-37 Coverage for adopted children
59A-46-37. Coverage for adopted children
A. No individual or group health maintenance organization contract shall be offered, issued or renewed in New Mexico on or after July 1, 1988, unless the contract covers adopted children of the subscriber or enrollee on the same basis as other dependents.
B. The coverage required by this section is effective from the date of placement for the purpose of adoption and continues unless the placement is disrupted prior to legal adoption and the child is removed from placement. Coverage shall include the necessary care and treatment of medical conditions existing prior to the date of placement.
C. As used in this section, "placement" means in the physical custody of the adoptive parent.
1978 Comp., § 59A-46-33, enacted by Laws 1988, ch. 89, § 2; recompiled as 1978 Comp., § 59A-46-37 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-38 Newly born children coverage
59A-46-38. Newly born children coverage
A. All individual and group health maintenance organization contracts delivered or issued for delivery in this state shall also provide that the health benefits applicable for children shall be payable with respect to a newly born child of the subscriber or the subscriber's spouse from the moment of birth.
B. All individual and group health maintenance organization contracts delivered or issued for delivery in this state that do not provide health benefits applicable for children shall provide for an option to add to the coverage any newly born child of the insured provided that the requirements of Subsection D of this section have been met.
C. The coverage for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, where necessary to protect the life of the infant, transportation, including air transport, to the nearest available tertiary care facility for newly born infants.
D. If a specific payment is required to provide coverage for a child, the contract may require that a notification of birth of a newly born child and payment must be furnished to the health maintenance organization within thirty-one days after the date of birth in order to have the coverage from birth.
E. As used in this section and in Section 59A-46-28 NMSA 1978 [59A-46-39 NMSA 1978], "tertiary care facility" means a hospital unit which provides complete perinatal care and intensive care of intrapartum and perinatal high-risk patients with responsibilities for coordination of transport, communication, education and data analysis systems for the geographic area served.
Laws 1984, ch. 127, § 874; 1993, ch. 169, § 2; 1978 Comp., § 59A-46-27, recompiled as § 59A-46-38 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-38.1 Coverage of children
59A-46-38.1. Coverage of children
A. An insurer shall not deny enrollment of a child under the health plan of the child's parent on the grounds that the child:
(1) was born out of wedlock;
(2) is not claimed as a dependent on the parent's federal tax return; or
(3) does not reside with the parent or in the insurer's service area.
B. When a child has health coverage through an insurer of a noncustodial parent, the insurer shall:
(1) provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;
(2) permit the custodial parent or the provider, with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent; and
(3) make payments on claims submitted in accordance with Paragraph (2) of this subsection directly to the custodial parent, the provider or the state medicaid agency.
C. When a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage, the insurer shall be required:
(1) to permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;
(2) if the parent is enrolled but fails to make application to obtain coverage for the child, to enroll the child under family coverage upon application of the child's other parent, the state agency administering the medicaid program or the state agency administering 42 U.S.C. Sections 651 through 669, the child support enforcement program; and
(3) not to disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:
(a) the court or administrative order is no longer in effect; or
(b) the child is or will be enrolled in comparable health coverage through another insurer that will take effect not later than the effective date of disenrollment.
D. An insurer shall not impose requirements on a state agency that has been assigned the rights of an individual eligible for medical assistance under the medicaid program and covered for health benefits from the insurer that are different from requirements applicable to an agent or assignee of any other individual so covered.
E. An insurer shall provide coverage for children, from birth through three years of age, for or under the family, infant, toddler program administered by the early childhood education and care department, provided eligibility criteria are met, for a maximum benefit of three thousand five hundred dollars ($3,500) annually for medically necessary early intervention services provided as part of an individualized family service plan and delivered by certified and licensed personnel who are working in early intervention programs approved by the early childhood education and care department. No payment under this subsection shall be applied against any maximum lifetime or annual limits specified in the policy, health benefits plan or contract.
1978 Comp., § 59A-46-38.1, enacted by Laws 1994, ch. 64, § 9; 2005, ch. 157, § 4; 2019, ch. 48, § 32.
NMSA 1978, § 59A-46-38.2 Childhood immunization coverage required
59A-46-38.2. Childhood immunization coverage required
A. Each individual and group health maintenance contract delivered or issued for delivery in this state shall provide coverage for childhood immunizations, in accordance with the current schedule of immunizations recommended by the American academy of pediatrics, including coverage for all medically necessary booster doses of all immunizing agents used in childhood immunizations.
B. Coverage for childhood immunizations and necessary booster doses may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract.
1978 Comp., § 59A-46-38.2, enacted by Laws 1997, ch. 250, § 4.
NMSA 1978, § 59A-46-38.3 Maximum age of dependent
59A-46-38.3. Maximum age of dependent
Each individual or group health maintenance organization contract delivered or issued for delivery or renewed in New Mexico that provides coverage for an enrollee's dependents shall not terminate coverage of an unmarried dependent by reason of the dependent's age before the dependent's twenty-sixth birthday, regardless of whether the dependent is enrolled in an educational institution; provided that this requirement does not apply to the medicaid managed care system.
Laws 2003, ch. 391, § 5; 2005, ch. 41, § 2; 2021, ch. 108, § 27.
NMSA 1978, § 59A-46-38.4 Coverage of circumcision for newborn males
59A-46-38.4. Coverage of circumcision for newborn males
An individual or group health maintenance organization policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in the state shall provide coverage for circumcision for newborn males.
Laws 2004, ch. 122, § 8.
NMSA 1978, § 59A-46-38.5 Hearing aid coverage for children required
59A-46-38.5. Hearing aid coverage for children required
A. An individual or group health maintenance organization contract delivered, issued for delivery or renewed in this state shall provide coverage for a hearing aid and any related service for the full cost of one hearing aid per hearing-impaired ear up to two thousand two hundred dollars ($2,200) every thirty-six months for hearing aids for insured children under eighteen years of age or under twenty-one years of age if still attending high school. The insured may choose a higher priced hearing aid and may pay the difference in cost above the two-thousand-two-hundred-dollar ($2,200) limit as provided in this subsection without financial or contractual penalty to the insured or to the provider of the hearing aid.
B. An insurer that delivers, issues for delivery or renews in this state an individual or group health maintenance organization contract may make available to the policyholder the option of purchasing additional hearing aid coverage that exceeds the services described in this section.
C. Hearing aid coverage offered shall include fitting and dispensing services, including providing ear molds as necessary to maintain optimal fit, provided by an audiologist, a hearing aid dispenser or a physician, licensed in New Mexico. A health maintenance organization has the discretion to determine the provider of hearing aids with which it contracts. Nothing in this section shall be construed to preclude a health maintenance organization from conducting medical necessity or utilization review for hearing aids and related services.
D. The provisions of this section do not apply to short-term travel, accident-only or limited or specified disease policies.
E. Coverage for hearing aids may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.
F. For the purposes of this section, "hearing aid" means durable medical equipment that is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by children.
Laws 2007, ch. 356, § 4.
NMSA 1978, § 59A-46-39 Maternity transport required
59A-46-39. Maternity transport required
All individual and group health maintenance organization contracts delivered or issued for delivery in this state which provide maternity coverage shall also provide, where necessary to protect the life of the infant or mother, coverage for transportation, including air transport, for the medically high-risk pregnant woman with an impending delivery of a potentially viable infant to the nearest available tertiary care facility as defined in Section 874 [59A-46-38 NMSA 1978] of this article for newly born infants.
Laws 1984, ch. 127, § 875; 1978 Comp., § 59A-46-28, recompiled as § 59A-46-39 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-40 Home health care service option required
59A-46-40. Home health care service option required
A. Each health maintenance organization which delivers or issues for delivery in this state an individual or group contract shall make available to the contract holder the option of home health care coverage which includes benefits for the services described in this section.
B. Home health care coverage offered shall include:
(1) services provided by a registered nurse or a licensed practical nurse;
(2) health services provided by physical, occupational and respiratory therapists and speech pathologists; and
(3) health services provided by a home health aide.
C. Home health care coverage may be limited to:
(1) services provided on the written order of a licensed physician, provided such order is renewed at least every sixty days;
(2) services provided, directly or through contractual agreements, by a home health agency licensed in the state in which the home health services are delivered; and
(3) services, as set forth in Subsection B of this section, without which the insured would have to be hospitalized.
D. Coverage shall be provided for at least one hundred home visits per enrollee per year, with each home visit including up to four hours of home health care services.
E. For the purposes of this section, "home health care" means health services provided on a part-time, intermittent basis to an individual confined to his home due to physical illness.
Laws 1984, ch. 127, § 876; 1978 Comp., § 59A-46-29, recompiled as § 59A-46-40 by Laws 1993, ch. 266, § 31.
NMSA 1978, § 59A-46-41 Coverage for mammograms
59A-46-41. Coverage for mammograms
Each individual and group health maintenance organization contract delivered or issued for delivery in this state shall provide coverage for low-dose screening mammograms for determining the presence of breast cancer. Such coverage shall make available one baseline mammogram to persons age thirty-five through thirty-nine, one mammogram biennially to persons age forty through forty-nine and one mammogram annually to persons age fifty and over. After July 1, 1992, coverage shall be available only for screening mammograms obtained on equipment designed specifically to perform low-dose mammography in imaging facilities that have met American college of radiology accreditation standards for mammography.
Laws 1990, ch. 5, § 1; 1978 Comp., § 59A-46-35, recompiled as § 59A-46-41 by Laws 1993, ch. 266, § 31; 2023, ch. 12, § 7.
NMSA 1978, § 59A-46-41.1 Mastectomies and lymph node dissection; minimum hospital stay coverage required
59A-46-41.1. Mastectomies and lymph node dissection; minimum hospital stay coverage required
A. Each individual and group health maintenance contract delivered or issued for delivery in this state shall provide coverage for not less than forty-eight hours of inpatient care following a mastectomy and not less than twenty-four hours of inpatient care following a lymph node dissection for the treatment of breast cancer.
B. Nothing in this section shall be construed as requiring the provision of inpatient coverage where the attending physician and patient determine that a shorter period of hospital stay is appropriate.
C. Coverage for minimum inpatient hospital stays for mastectomies and lymph node dissections for the treatment of breast cancer may be subject to deductibles and co-insurance consistent with those imposed on other benefits under the same contract.
1978 Comp., § 59A-46-41.1, enacted by Laws 1997, ch. 249, § 4.
NMSA 1978, § 59A-46-41.2 Prior authorization for gynecological or obstetrical ultrasounds prohibited
59A-46-41.2. Prior authorization for gynecological or obstetrical ultrasounds prohibited
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides coverage for gynecological or obstetrical ultrasounds shall not require prior authorization for gynecological or obstetrical ultrasounds.
B. Nothing in this section shall be construed to require payment for a gynecological or obstetrical ultrasound that is not:
(1) medically necessary; or
(2) a covered benefit.
C. As used in this section, "prior authorization" means advance approval that is required by a health maintenance organization as a condition precedent to payment for medical care or related benefits rendered to a covered person, including prospective or utilization review conducted prior to the provision of covered medical care or related benefits.
Laws 2019, ch. 182, § 5.
NMSA 1978, § 59A-46-41.3 Diagnostic and supplemental breast examinations
59A-46-41.3. Diagnostic and supplemental breast examinations
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that provides coverage for diagnostic and supplemental breast examinations shall not impose cost sharing for diagnostic and supplemental breast examinations.
B. The provisions of this section do not apply to excepted benefit plans as provided pursuant to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978], catastrophic plans as defined pursuant to 42 USCA Section 18022(e) or high deductible health plans with health savings accounts until an eligible insured's deductible has been met, unless otherwise allowed pursuant to federal law.
C. As used in this section:
(1) "cost sharing" means a deductible, coinsurance, copayment and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense;
(2) "diagnostic breast examination" means a medically necessary and clinically appropriate examination of the breast using diagnostic mammography, breast magnetic resonance imaging or breast ultrasound that evaluates an abnormality:
(a) seen or suspected from a screening examination for breast cancer; or
(b) detected by another means of examination; and
(3) "supplemental breast examination" means a medically necessary and clinically appropriate examination of the breast using breast magnetic resonance imaging or breast ultrasound that is:
(a) used to screen for breast cancer when there is no abnormality seen or suspected; and
(b) based on personal or family medical history or additional factors that may increase the individual's risk of breast cancer.
Laws 2023, ch. 12, § 4.
NMSA 1978, § 59A-46-42 Coverage for cytologic and human papillomavirus screening
59A-46-42. Coverage for cytologic and human papillomavirus screening
A. Each individual and group health maintenance organization contract delivered or issued for delivery in this state shall provide coverage for cytologic and human papillomavirus screening to determine the presence of precancerous or cancerous conditions and other health problems. The coverage shall make available cytologic screening, as determined by the health care provider in accordance with national medical standards, for women who are eighteen years of age or older and for women who are at risk of cancer or at risk of other health conditions that can be identified through cytologic screening. The coverage shall make available human papillomavirus screening once every three years for women aged thirty and older.
B. Coverage for cytologic and human papillomavirus screening may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract.
C. For the purposes of this section:
(1) "cytologic screening" means a Papanicolaou test and pelvic exam for asymptomatic as well as symptomatic women;
(2) "health care provider" means any person licensed within the scope of his practice to perform cytologic and human papillomavirus screening, including physicians, physician assistants, certified nurse-midwives and certified nurse practitioners; and
(3) "human papillomavirus screening" means a test approved by the federal food and drug administration for detection of the human papillomavirus.
Laws 1992, ch. 56, § 1; 1978 Comp., § 59A-46-36, recompiled by § 59A-46-42 by Laws 1993, ch. 266, § 31; 2005, ch. 133, § 1.
NMSA 1978, § 59A-46-42.1 Coverage for the human papillomavirus vaccine
59A-46-42.1. Coverage for the human papillomavirus vaccine
A. An individual or group health maintenance organization contract delivered, issued for delivery or renewed in this state shall provide coverage for the human papillomavirus vaccine in accordance with the current standards of the federal centers for disease control and prevention.
B. Coverage for the human papillomavirus vaccine may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.
C. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified disease policies.
D. For the purposes of this section, "human papillomavirus vaccine" means a vaccine approved by the federal food and drug administration used for the prevention of human papillomavirus infection and cervical precancers.
Laws 2007, ch. 278, § 3; 2021, ch. 108, § 28.
NMSA 1978, § 59A-46-43 Coverage for individuals with diabetes
59A-46-43. Coverage for individuals with diabetes
A. Each individual and group health maintenance organization contract delivered or issued for delivery in this state shall provide coverage for individuals with insulin-using diabetes, with non-insulin-using diabetes and with elevated blood glucose levels induced by pregnancy. This coverage shall be a basic health care service and shall entitle each individual to the medically accepted standard of medical care for diabetes and benefits for diabetes treatment as well as diabetes supplies, and this coverage shall not be reduced or eliminated.
B. Except as provided in this subsection, coverage for individuals with diabetes may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract, as long as the annual deductibles or coinsurance for benefits are no greater than the annual deductibles or coinsurance established for similar benefits within a given contract. The amount an individual with diabetes is required to pay for a preferred formulary prescription insulin drug or a medically necessary alternative is an amount not to exceed a total of twenty-five dollars ($25.00) per thirty-day supply.
C. When prescribed or diagnosed by a health care practitioner with prescribing authority, all individuals with diabetes as described in Subsection A of this section enrolled under an individual or group health maintenance organization contract shall be entitled to the following equipment, supplies and appliances to treat diabetes:
(1) blood glucose monitors, including those for individuals with disabilities, including the legally blind;
(2) test strips for blood glucose monitors;
(3) visual reading urine and ketone strips;
(4) lancets and lancet devices;
(5) insulin;
(6) injection aids, including those adaptable to meet the needs of individuals with disabilities, including the legally blind;
(7) syringes;
(8) prescriptive oral agents for controlling blood sugar levels;
(9) medically necessary podiatric appliances for prevention of feet complications associated with diabetes, including therapeutic molded or depth-inlay shoes, functional orthotics, custom molded inserts, replacement inserts, preventive devices and shoe modifications for prevention and treatment; and
(10) glucagon emergency kits.
D. When prescribed or diagnosed by a health care practitioner with prescribing authority, all individuals with diabetes as described in Subsection A of this section enrolled under an individual or group health maintenance contract shall be entitled to the following basic health care services:
(1) diabetes self-management training that shall be provided by a certified, registered or licensed health care professional with recent education in diabetes management, which shall be limited to:
(a) medically necessary visits upon the diagnosis of diabetes;
(b) visits following a diagnosis from a health care practitioner that represents a significant change in the patient's symptoms or condition that warrants changes in the patient's self-management; and
(c) visits when re-education or refresher training is prescribed by a health care practitioner with prescribing authority; and
(2) medical nutrition therapy related to diabetes management.
E. When new or improved equipment, appliances, prescription drugs for the treatment of diabetes, insulin or supplies for the treatment of diabetes are approved by the federal food and drug administration, each individual or group health maintenance organization contract shall:
(1) maintain an adequate formulary to provide these resources to individuals with diabetes; and
(2) guarantee reimbursement or coverage for the equipment, appliances, prescription drug, insulin or supplies described in this subsection within the limits of the health care plan, policy or certificate.
F. A health maintenance organization that requires an enrollee to use a specific network provider or to purchase equipment, appliances, supplies or insulin or prescription drugs for the treatment or management of diabetes from a specific durable medical equipment supplier or other supplier as a condition of coverage, payment or reimbursement shall:
(1) maintain an adequate network of durable medical equipment suppliers and other suppliers to provide covered persons with medically necessary diabetes resources whether covered under the health maintenance organization contract's prescription drug or medical benefit;
(2) have network contracts in place for the entire contract period and shall not allow contracts with network providers, durable medical equipment suppliers and other suppliers to lapse or terminate without ensuring the availability of a replacement and continuity of care; provided that single-case agreements do not satisfy the requirements of Paragraph (1) of this subsection or this paragraph;
(3) monitor network providers, durable medical equipment suppliers and other network suppliers to ensure that medically necessary equipment, appliances, supplies and insulin or other prescription drugs are being delivered to an enrollee in a timely manner and when needed by the enrollee;
(4) guarantee reimbursement to an enrollee within thirty days following receipt of a written demand from the enrollee who pays out of pocket for necessary equipment, appliances, supplies and insulin or other prescription drugs described in this section that are not delivered timely to the enrollee and the portion of payment for which the patient is responsible shall not exceed the amount for the same covered benefit obtained from a contracted supplier;
(5) pay interest at the rate of eighteen percent per year on the amount of reimbursement due to an enrollee if not paid within thirty days as required by Paragraph (4) of this subsection;
(6) beginning on April 1, 2024, submit a written report each quarter to the superintendent for the previous quarter on the following metrics:
(a) the number of written demands for reimbursement of out-of-pocket expenses from enrollees received by the health maintenance organization;
(b) the number of out-of-pocket claims for reimbursement paid and the aggregate amount of claims reimbursed by the health maintenance organization within the time required by Paragraph (4) of this subsection;
(c) the number of out-of-pocket claims for reimbursement paid more than thirty days following receipt of a written demand and the aggregate amount of these payments, excluding interest; and
(d) the aggregate amount of interest paid by the health maintenance organization pursuant to Paragraph (5) of this subsection; and
(7) beginning on April 1, 2024, submit a written report each quarter for the previous quarter to the superintendent with the following information for each durable medical equipment supplier or other supplier that was under contract with the health maintenance organization or its agent during the previous quarter:
(a) the name, address and telephone number of each supplier and, if applicable, the corresponding date upon which the respective supplier's contract expired, lapsed or was terminated during the previous quarter;
(b) the percentage of total deliveries, by description of item, that did not meet the delivery requirements specified in Paragraph (3) of this subsection; and
(c) the number of complaints received by the health maintenance organization or its agent during the previous quarter related to late deliveries, incomplete orders or incorrect orders, respectively.
G. The superintendent shall annually audit all health maintenance organizations offering contracts as described in Subsection A of this section for compliance with the requirements of this section. If the superintendent determines that a health maintenance organization has not complied with the requirements of this section, the superintendent shall impose corrective action or use any other enforcement mechanism available to the superintendent to obtain the health maintenance organization's compliance with this section.
H. Absent a change in diagnosis or in an enrollee's management or treatment of diabetes or its complications, a health maintenance organization shall not require more than one prior authorization per policy period for any single drug or category of item enumerated in this section if prescribed as medically necessary by the enrollee's health care practitioner. Changes in the prescribed dose of a drug; quantities of supplies needed to administer a prescribed drug; quantities of blood glucose self-testing equipment and supplies; or quantities of supplies needed to use or operate devices for which an enrollee has received prior authorization during the policy year shall not be subject to additional prior authorization requirements in the same policy year if prescribed as medically necessary by the enrollee's health care practitioner. Nothing in this subsection shall be construed to require payment for diabetes resources that are not a covered benefit.
I. The provisions of this section do not apply to short-term travel, accident-only or limited or specified disease policies.
J. For purposes of this section, "basic health care benefits":
(1) means benefits for medically necessary services consisting of preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services; and
(2) does not include services for alcohol or drug abuse, dental or long-term rehabilitation treatment.
1978 Comp., § 59A-46-43, enacted by Laws 1997, ch. 7, § 3; 1997, ch. 255, § 3; 2020, ch. 36, § 3; 2023, ch. 50, § 4; 2025, ch. 36, § 3.
NMSA 1978, § 59A-46-43.2 Coverage for medical diets for genetic inborn errors of metabolism
59A-46-43.2. Coverage for medical diets for genetic inborn errors of metabolism
As of July 1, 2003, each health maintenance organization that delivers or issues for delivery in the state an individual or group contract shall provide coverage for the treatment of genetic inborn errors of metabolism as set forth in Chapter 59A, Article 22 NMSA 1978.
Laws 2003, ch. 192, § 2.
NMSA 1978, § 59A-46-44 Coverage for contraception
59A-46-44. Coverage for contraception
A. Each individual and group health maintenance organization contract delivered or issued for delivery in this state that provides a prescription drug benefit shall provide, at a minimum, the following coverage:
(1) at least one product or form of contraception in each of the contraceptive method categories identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral contraceptive pills to reflect the variety of oral contraceptives approved by the federal food and drug administration; and
(3) clinical services related to the provision or use of contraception, including consultations, examinations, procedures, ultrasound, anesthesia, patient education, counseling, device insertion and removal, follow-up care and side-effects management.
B. Except as provided in Subsection C of this section, the coverage required pursuant to this section shall not be subject to:
(1) enrollee cost sharing;
(2) utilization review;
(3) prior authorization or step-therapy requirements; or
(4) any other restrictions or delays on the coverage.
C. A health maintenance organization may discourage brand-name pharmacy drugs or items by applying cost sharing to brand-name drugs or items when at least one generic or therapeutic equivalent is covered within the same method of contraception without patient cost sharing; provided that when an enrollee's health care provider determines that a particular drug or item is medically necessary, the individual or group health maintenance organization contract shall cover the brand-name pharmacy drug or item without cost sharing. Medical necessity may include considerations such as severity of side effects, differences in permanence or reversibility of contraceptives and ability to adhere to the appropriate use of the drug or item, as determined by the attending provider.
D. An individual or group health maintenance organization contract shall grant an enrollee an expedited hearing to appeal any adverse determination made relating to the provisions of this section. The process for requesting an expedited hearing pursuant to this subsection shall:
(1) be easily accessible, transparent, sufficiently expedient and not unduly burdensome on an enrollee, the enrollee's representative or the enrollee's health care provider;
(2) defer to the determination of the enrollee's health care provider; and
(3) provide for a determination of the claim according to a time frame and in a manner that takes into account the nature of the claim and the medical exigencies involved for a claim involving an urgent health care need.
E. An individual or group health maintenance organization contract shall not require a prescription for any drug, item or service that is available without a prescription.
F. An individual or group health maintenance organization contract shall provide coverage and shall reimburse a health care provider or dispensing entity on a per-unit basis for dispensing a six-month supply of contraceptives at one time; provided that the contraceptives are prescribed and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to prescribe six months of contraceptives at one time; or
(2) permit an individual or group health maintenance organization contract to limit coverage or impose cost sharing for an alternate method of contraception if an enrollee changes contraceptive methods before exhausting a previously dispensed supply.
H. The provisions of this section shall not apply to short-term travel, accident-only, hospital-indemnity-only, limited-benefit or specified disease health benefits plans.
I. The provisions of this section apply to individual or group health maintenance organization contracts delivered or issued for delivery after January 1, 2020.
J. For the purposes of this section:
(1) "contraceptive method categories identified by the federal food and drug administration":
(a) means tubal ligation; sterilization implant; copper intrauterine device; intrauterine device with progestin; implantable rod; contraceptive shot or injection; combined oral contraceptives; extended or continuous use oral contraceptives; progestin-only oral contraceptives; patch; vaginal ring; diaphragm with spermicide; sponge with spermicide; cervical cap with spermicide; male and female condoms; spermicide alone; vasectomy; ulipristal acetate; levonorgestrel emergency contraception; and any additional contraceptive method categories approved by the federal food and drug administration; and
(b) does not mean a product that has been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible, copayment or coinsurance that an enrollee is required to pay in accordance with the terms of an individual or group health maintenance organization contract; and
(3) "health care provider" means an individual licensed to provide health care in the ordinary course of business.
K. A religious entity purchasing individual or group health maintenance organization coverage may elect to exclude prescription contraceptive drugs or devices from the health coverage purchased.
Laws 2001, ch. 14, § 3; 2003, ch. 202, § 13; 2019, ch. 263, § 7.
NMSA 1978, § 59A-46-45 Coverage for smoking cessation treatment
59A-46-45. Coverage for smoking cessation treatment
A. An individual or group health maintenance organization contract that is delivered or issued for delivery in this state and that offers maternity benefits shall offer coverage for smoking cessation treatment.
B. Coverage for smoking cessation treatment may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract.
Laws 2003, ch. 337, § 4.
NMSA 1978, § 59A-46-46 Coverage of alpha-fetoprotein IV screening test
59A-46-46. Coverage of alpha-fetoprotein IV screening test
An individual or group health maintenance organization policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in the state shall provide coverage for an alpha-fetoprotein IV screening test for pregnant women, generally between sixteen and twenty weeks of pregnancy, to screen for certain genetic abnormalities in the fetus.
Laws 2004, ch. 122, § 7.
NMSA 1978, § 59A-46-47 Coverage of part-time employees
59A-46-47. Coverage of part-time employees
A health maintenance organization that provides coverage for health care services pursuant to the Health Maintenance Organization Law shall make available, upon an employer's request prior to issuance, delivery or renewal, coverage for regular part-time employees who work or are expected to work an average of at least twenty hours per week over a six-month period. Nothing in this section shall be construed to require an employer to offer or provide coverage for regular part-time employees.
Laws 2005, ch. 42, § 3.
NMSA 1978, § 59A-46-48 Coverage of colorectal cancer screening
59A-46-48. Coverage of colorectal cancer screening
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state shall provide coverage for colorectal screening for determining the presence of precancerous or cancerous conditions and other health problems. The coverage shall make available colorectal cancer screening, as determined by the health care provider in accordance with the evidence-based recommendations established by the United States preventive services task force.
B. Coverage for colorectal screening may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.
Laws 2007, ch. 17, § 3.
NMSA 1978, § 59A-46-49 General anesthesia and hospitalization for dental surgery
59A-46-49. General anesthesia and hospitalization for dental surgery
A. An individual or group health maintenance organization contract delivered, issued for delivery or renewed in this state shall provide coverage for hospitalization and general anesthesia provided in a hospital or ambulatory surgical center for dental surgery for the following:
(1) insureds exhibiting physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results;
(2) insureds for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy;
(3) insured children or adolescents who are extremely uncooperative, fearful, anxious or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity;
(4) insureds with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised; or
(5) other procedures for which hospitalization or general anesthesia in a hospital or ambulatory surgical center is medically necessary.
B. The provisions of this section do not apply to short-term travel, accident-only or limited or specified disease policies.
C. Coverage for dental surgery may be subject to copayments, deductibles and coinsurance subject to network and prior authorization requirements consistent with those imposed on other benefits under the same policy, plan or certificate.
Laws 2007, ch. 218, § 4.
NMSA 1978, § 59A-46-50 Coverage for autism spectrum disorder diagnosis and treatment
59A-46-50. Coverage for autism spectrum disorder diagnosis and treatment
A. An individual or group health maintenance contract that is delivered, issued for delivery or renewed in this state shall provide coverage to an enrollee for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.
B. Coverage required pursuant to Subsection A of this section:
(1) shall be limited to treatment that is prescribed by the enrollee's treating physician in accordance with a treatment plan;
(2) shall not be subject to annual or lifetime dollar limits;
(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;
(4) may be subject to other general exclusions and limitations of the health maintenance organization contract, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and
(5) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three to twenty-two years of age who have autism spectrum disorder.
C. Coverage for treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis shall not be denied to an enrollee on the basis of the enrollee's age.
D. The coverage required pursuant to Subsection A of this section shall not be subject to deductibles or coinsurance provisions that are less favorable to an enrollee than the deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health maintenance contract, except as otherwise provided in Subsection B of this section.
E. A carrier shall not deny or refuse to issue a health maintenance organization contract for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health maintenance organization coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
F. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health maintenance organization contract to pay claims appropriately. These elements include:
(1) the diagnosis;
(2) the proposed treatment by types;
(3) the frequency and duration of treatment;
(4) the anticipated outcomes stated as goals;
(5) the frequency with which the treatment plan will be updated; and
(6) the signature of the treating physician.
G. This section shall not be construed as limiting benefits and coverage otherwise available to an enrollee under a health maintenance organization contract.
H. The provisions of this section shall not apply to contracts, plans or policies intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance contracts, plans or policies.
I. As used in this section:
(1) "autism spectrum disorder" means:
(a) a condition that meets the diagnostic criteria for the pervasive developmental disorders published in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; or
(b) a condition diagnosed as autistic disorder, Asperger's disorder, pervasive development disorder not otherwise specified, Rett's disorder or childhood disintegrative disorder pursuant to diagnostic criteria published in a previous edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain and restore to the maximum extent practicable the functioning of an individual.
Laws 2009, ch. 74, § 3; 2019, ch. 119, § 5.
NMSA 1978, § 59A-46-50.1 Coverage for orally administered anticancer medications; limits on patient costs
59A-46-50.1. Coverage for orally administered anticancer medications; limits on patient costs
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides coverage for cancer treatment shall provide coverage for a prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits by the plan.
B. A health maintenance organization shall not increase patient cost-sharing for anticancer medications in order to achieve compliance with the provisions of this section.
C. Coverage of orally administered anticancer medication shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medication used to kill or slow the growth of cancerous cells.
D. As used in this section, "health maintenance organization contract":
(1) means:
(a) a health maintenance organization; or
(b) a managed care organization; and
(2) does not include individual policies intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policies.
Laws 2011, ch. 55, § 4.
NMSA 1978, § 59A-46-50.2 Coverage of prescription eye drop refills
59A-46-50.2. Coverage of prescription eye drop refills
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides coverage for prescription eye drops shall not deny coverage for a renewal of prescription eye drops when:
(1) the renewal is requested by the insured at least twenty-three days for a thirty-day supply of eye drops, forty-five days for a sixty-day supply of eye drops or sixty-eight days for a ninety-day supply of eye drops from the later of the date that the original prescription was dispensed to the insured or the date that the last renewal of the prescription was dispensed to the insured; and
(2) the prescriber indicates on the original prescription that additional quantities are needed and that the renewal requested by the insured does not exceed the number of additional quantities needed.
B. As used in this section, "prescriber" means a person who is authorized pursuant to the New Mexico Drug, Device and Cosmetic Act [Chapter 26, Article 1 NMSA 1978] to prescribe prescription eye drops.
Laws 2012, ch. 27, § 4.
NMSA 1978, § 59A-46-50.3 Coverage for telemedicine services
59A-46-50.3. Coverage for telemedicine services
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state shall provide coverage for services provided via telemedicine to the same extent that the contract covers the same services when those services are provided via in-person consultation or contact. A carrier shall not impose any unique condition for coverage of services provided via telemedicine.
B. A carrier shall not impose an originating-site restriction with respect to telemedicine services or distinguish between telemedicine services provided to patients in rural locations and those provided to patients in urban locations; provided that the provisions of this section shall not be construed to require coverage of an otherwise noncovered benefit.
C. A determination by a health maintenance organization that health care services delivered through the use of telemedicine are not covered under the plan shall be subject to review and appeal pursuant to the Patient Protection Act [Chapter 59A, Article 57 NMSA 1978].
D. The provisions of this section shall not apply in the event that federal law requires the state to make payments on behalf of enrollees to cover the costs of implementing this section.
E. Nothing in this section shall require a health care provider to be physically present with a patient at the originating site unless the consulting telemedicine provider deems it necessary.
F. A carrier shall not limit coverage of services delivered via telemedicine only to those health care providers who are members of the health maintenance organization contract provider network where no in-network provider is available and accessible, as availability and accessibility are defined in network adequacy standards issued by the superintendent.
G. A carrier may charge a deductible, copayment or coinsurance for a health care service delivered via telemedicine if it does not exceed the deductible, copayment or coinsurance applicable to a service delivered via in-person consultation or contact.
H. A carrier shall not impose any annual or lifetime dollar maximum on coverage for services delivered via telemedicine, other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract, or impose upon any person receiving benefits pursuant to this section any copayment, coinsurance or deductible amounts, or any contract year, calendar year, lifetime or other durational benefit limitation or maximum for benefits or services, that is not equally imposed upon all terms and services covered under the contract.
I. A carrier shall reimburse for health care services delivered via telemedicine on the same basis and at least the same rate that the carrier reimburses for comparable services delivered via in-person consultation or contact.
J. Telemedicine used to provide clinical services shall be encrypted and shall conform to state and federal privacy laws.
K. The provisions of this section shall not apply to an individual or group health maintenance organization contract intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.
L. As used in this section:
(1) "consulting telemedicine provider" means a health care provider that delivers telemedicine services from a location remote from an originating site;
(2) "in real time" means occurring simultaneously, instantaneously or within seconds of an event so that there is little or no noticeable delay between two or more events;
(3) "originating site" means a place at which a patient is physically located and receiving health care services via telemedicine;
(4) "store-and-forward technology" means electronic information, imaging and communication, including interactive audio, video and data communication, that is transferred or recorded or otherwise stored for asynchronous use; and
(5) "telemedicine" means the use of telecommunications and information technology to provide clinical health care from a distance. "Telemedicine" allows health care professionals to evaluate, diagnose and treat patients in remote locations using telecommunications and information technology in real time or asynchronously, including the use of interactive simultaneous audio and video or store-and-forward technology, or remote patient monitoring and telecommunications in order to deliver health care services to a site where the patient is located, along with the use of electronic media and health information. "Telemedicine" allows patients in remote locations to access medical expertise without travel.
Laws 2013, ch. 105, § 4; 2019, ch. 255, § 4.
NMSA 1978, § 59A-46-50.4 Prescription drugs; prohibited formulary changes; notice requirements
59A-46-50.4. Prescription drugs; prohibited formulary changes; notice requirements
A. As of January 1, 2014, an individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides prescription drug benefits categorized or tiered for purposes of cost-sharing through deductibles or coinsurance obligations shall not make any of the following changes to coverage for a prescription drug within one hundred twenty days of any previous change to coverage for that prescription drug, unless a generic version of the prescription drug is available:
(1) reclassify a drug to a higher tier of the formulary;
(2) reclassify a drug from a preferred classification to a non-preferred classification, unless that reclassification results in the drug moving to a lower tier of the formulary;
(3) increase the cost-sharing, copayment, deductible or co-insurance charges for a drug;
(4) remove a drug from the formulary;
(5) establish a prior authorization requirement;
(6) impose or modify a drug's quantity limit; or
(7) impose a step-therapy restriction.
B. The health maintenance organization shall give the affected subscriber at least sixty days' advance written notice of the impending change when it is determined that one of the following modifications will be made to a formulary:
(1) reclassification of a drug to a higher tier of the formulary;
(2) reclassification of a drug from a preferred classification to a non-preferred classification, unless that reclassification results in the drug moving to a lower tier of the formulary;
(3) an increase in the cost-sharing, copayment, deductible or coinsurance charges for a drug;
(4) removal of a drug from the formulary;
(5) addition of a prior authorization requirement;
(6) imposition or modification of a drug's quantity limit; or
(7) imposition of a step-therapy restriction for a drug.
C. Notwithstanding the provisions of Subsections A and B of this section, the health maintenance organization may immediately and without prior notice remove a drug from the formulary if the drug:
(1) is deemed unsafe by the federal food and drug administration; or
(2) has been removed from the market for any reason.
D. The health maintenance organization shall provide to each affected subscriber the following information in plain language regarding prescription drug benefits:
(1) notice that the health maintenance organization uses one or more drug formularies;
(2) an explanation of what the drug formulary is;
(3) a statement regarding the method the health maintenance organization uses to determine the prescription drugs to be included in or excluded from a drug formulary; and
(4) a statement of how often the health maintenance organization reviews the contents of each drug formulary.
E. As used in this section:
(1) "formulary" means the list of prescription drugs covered pursuant to a health maintenance organization contract; and
(2) "step therapy" means a protocol that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular patient are to be prescribed.
Laws 2013, ch. 138, § 4.
NMSA 1978, § 59A-46-50.5 Heart artery calcium scan coverage
59A-46-50.5. Heart artery calcium scan coverage
A. A group health maintenance organization contract, other than a small group health maintenance organization contract, that is delivered, issued for delivery or renewed in this state shall provide coverage for eligible enrollees to receive a heart artery calcium scan.
B. Coverage provided pursuant to this section shall:
(1) be limited to the provision of a heart artery calcium scan to an eligible enrollee to be used as a clinical management tool;
(2) be provided every five years if an eligible enrollee has previously received a heart artery calcium score of zero; and
(3) not be required for future heart artery calcium scans if an eligible enrollee receives a heart artery calcium score greater than zero.
C. At its discretion or as required by law, a carrier may offer or refuse coverage for further cardiac testing or procedures for eligible enrollees based upon the results of a heart artery calcium scan.
D. The provisions of this section do not apply to short-term travel, accident-only or limited or specified-disease policies, plans or certificates of health insurance.
E. As used in this section:
(1) "eligible enrollee" means an enrollee who:
(a) is a person between the ages of forty-five and sixty-five; and
(b) has an intermediate risk of developing coronary heart disease as determined by a health care provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to assess a person's ten-year cardiovascular disease risk, including a score calculated using a pooled cohort equation;
(2) "health care provider" means a physician, physician assistant, nurse practitioner or other health care professional authorized to furnish health care services within the scope of the professional's license; and
(3) "heart artery calcium scan" means a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function.
Laws 2020, ch. 79, § 4.
NMSA 1978, § 59A-46-52 Prescription drug prior authorization protocols
59A-46-52. Prescription drug prior authorization protocols
A. After January 1, 2014, a health maintenance organization shall accept the uniform prior authorization form developed pursuant to Sections 2 [59A-2-9.8 NMSA 1978] and 3 [61-11-6.2 NMSA 1978] of this 2013 act as sufficient to request prior authorization for prescription drug benefits.
B. No later than twenty-four months after the adoption of national standards for electronic prior authorization, a health insurer shall exchange prior authorization requests with providers who have e-prescribing capability.
C. If a health maintenance organization fails to use or accept the uniform prior authorization form or fails to respond within three business days upon receipt of a uniform prior authorization form, the prior authorization request shall be deemed to have been granted.
D. As used in this section, "health maintenance organization":
(1) means:
(a) a health maintenance organization; or
(b) a managed care organization; and
(2) does not include:
(a) a person that delivers, issues for delivery or renews an individual policy intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policy;
(b) a physician or a physician group to which a health maintenance organization has delegated financial risk for prescription drugs and that does not use a prior authorization process for prescription drugs; or
(c) a health maintenance organization or its affiliated providers if the health maintenance organization owns and operates its pharmacies and does not use a prior authorization process.
Laws 2013, ch. 170, § 7.
NMSA 1978, § 59A-46-52.1 Prescription drug coverage; step therapy protocols; clinical review criteria; exceptions
59A-46-52.1. Prescription drug coverage; step therapy protocols; clinical review criteria; exceptions
A. Each individual or group health maintenance organization contract delivered or issued for delivery in this state that provides a prescription drug benefit for which any step therapy protocols are required shall establish clinical review criteria for those step therapy protocols. The clinical review criteria shall be based on clinical practice guidelines that:
(1) recommend that the prescription drugs subject to step therapy protocols be taken in the specific sequence required by the step therapy protocol;
(2) are developed and endorsed by an interdisciplinary panel of experts that manages conflicts of interest among the members of the panel of experts by:
(a) requiring members to: 1) disclose any potential conflicts of interest with carriers, insurers, health care plans, pharmaceutical manufacturers, pharmacy benefits managers and any other entities; and 2) recuse themselves if there is a conflict of interest; and
(b) using analytical and methodological experts to work to provide objectivity in data analysis and ranking of evidence through the preparation of evidence tables and facilitating consensus;
(3) are based on high-quality studies, research and medical practice;
(4) are created pursuant to an explicit and transparent process that:
(a) minimizes bias and conflicts of interest;
(b) explains the relationship between treatment options and outcomes;
(c) rates the quality of the evidence supporting recommendations; and
(d) considers relevant patient subgroups and preferences; and
(5) take into account the needs of atypical patient populations and diagnoses.
B. In the absence of clinical guidelines that meet the requirements of Subsection A of this section, peer-reviewed publications may be substituted.
C. When a health maintenance organization contract restricts coverage of a prescription drug for the treatment of any medical condition through the use of a step therapy protocol, an enrollee and the practitioner prescribing the prescription drug shall have access to a clear, readily accessible and convenient process to request a step therapy exception determination. A carrier may use its existing medical exceptions process in accordance with the provisions of Subsections D through I of this section to satisfy this requirement. The process shall be made easily accessible for enrollees and practitioners on the carrier's publicly accessible website.
D. A carrier shall expeditiously grant an exception to the health maintenance organization contract's step therapy protocol, based on medical necessity and a clinically valid explanation from the patient's prescribing practitioner as to why a drug on the health maintenance organization contract's formulary that is therapeutically equivalent to the prescribed drug should not be substituted for the prescribed drug, if:
(1) the prescription drug that is the subject of the exception request is contraindicated or will likely cause an adverse reaction by or physical or mental harm to the patient;
(2) the prescription drug that is the subject of the exception request is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;
(3) while under the enrollee's current health maintenance organization contract, or under the enrollee's previous health coverage, the enrollee has tried the prescription drug that is the subject of the exception request or another prescription drug in the same pharmacologic class or with the same mechanism of action as the prescription drug that is the subject of the exception request and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; or
(4) the prescription drug required pursuant to the step therapy protocol is not in the best interest of the patient, based on clinical appropriateness, because the patient's use of the prescription drug is expected to:
(a) cause a significant barrier to the patient's adherence to or compliance with the patient's plan of care;
(b) worsen a comorbid condition of the patient; or
(c) decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.
E. Upon the granting of an exception to a health maintenance organization contract's step therapy protocol, a carrier shall authorize coverage for the prescription drug that is the subject of the exception request for no less than the duration of the therapeutic effect of the drug. A carrier shall include in its evidence of coverage language describing an enrollee's rights pursuant to this subsection.
F. A carrier shall respond with its decision on an enrollee's exception request within seventy-two hours of receipt. In cases where exigent circumstances exist, a carrier shall respond within twenty-four hours of receipt of the exception request. In the event the carrier does not respond to an exception request within the time frames required pursuant to this subsection, the exception request shall be granted.
G. A carrier's denial of a request for an exception for step therapy protocols shall be subject to review and appeal pursuant to the Patient Protection Act [Chapter 59A, Article 57 NMSA 1978].
H. After an enrollee has made an exception request in accordance with the provisions of this section, a carrier shall authorize continued coverage of a prescription drug that is the subject of the exception request pending the determination of the exception request.
I. The provisions of this section shall not be construed to prevent:
(1) a health maintenance organization contract from requiring a patient to try a biosimilar, interchangeable biologic or generic equivalent of a prescription drug before providing coverage for the equivalent brand-name prescription drug; or
(2) a practitioner from prescribing a prescription drug that the practitioner has determined to be medically necessary.
J. The superintendent shall promulgate rules as may be necessary to appropriately implement the provisions of this section.
K. Nothing in this section shall be interpreted to interfere with the superintendent's authority to regulate prescription drug coverage benefits under other state and federal law.
L. As used in this section, "medical necessity" or "medically necessary" means health care services determined by a practitioner, in consultation with the carrier, to be appropriate or necessary, according to:
(1) any applicable, generally accepted principles and practices of good medical care;
(2) practice guidelines developed by the federal government or national or professional medical societies, boards or associations; or
(3) any applicable clinical protocols or practice guidelines developed by the carrier consistent with federal, national and professional practice guidelines. These standards shall be applied to decisions related to the diagnosis or direct care and treatment of a physical or behavioral health condition, illness, injury or disease.
Laws 2018, ch. 9, § 5; 2024, ch. 42, § 5.
NMSA 1978, § 59A-46-52.2 Pharmacist prescriptive authority services; reimbursement parity
59A-46-52.2. Pharmacist prescriptive authority services; reimbursement parity
A carrier shall reimburse a participating provider that is a certified pharmacist clinician or pharmacist certified to provide a prescriptive authority service who provides a service pursuant to an individual or group contract at the standard contracted rate that the carrier reimburses, for the same service under that individual or group contract, any licensed physician or physician assistant licensed pursuant to the Medical Practice Act [Chapter 41, Article 5 NMSA 1978] or any advanced practice certified nurse practitioner licensed pursuant to the Nursing Practice Act [Chapter 61, Article 3 NMSA 1978].
Laws 2020, ch. 58, § 5; 2021, ch. 54, § 13.
NMSA 1978, § 59A-46-52.3 Calculating an enrollee's cost-sharing obligation for prescription drug coverage
59A-46-52.3. Calculating an enrollee's cost-sharing obligation for prescription drug coverage
A. When calculating an enrollee's cost-sharing obligation for covered prescription drugs, pursuant to an individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state, the insurer shall credit the enrollee for the full value of any discounts provided or payments made by third parties at the time of the prescription drug claim.
B. Beginning on or after January 1, 2024, an insurer shall not charge a different cost-sharing amount for:
(1) prescription drugs or pharmacy services obtained at a non-affiliated pharmacy; or
(2) administration of prescription drugs at different infusion sites; provided that an insurer may communicate with an insured regarding lower-cost sites of service.
C. Beginning on or after January 1, 2024, an insurer shall not require an insured to make a payment at the point of sale for a covered prescription drug in an amount greater than the least of the:
(1) applicable cost-sharing amount for the prescription drug;
(2) amount an insured would pay for the prescription drug if the insured purchased the prescription drug without using a health benefits plan or any other source of prescription drug benefits or discounts;
(3) total amount the pharmacy will be reimbursed for the prescription drug from the insurer, including the cost-sharing amount paid by an insurer; or
(4) value of the rebate from the manufacturer provided to the insurer or its pharmacy benefits manager for the prescribed drug.
D. Beginning on or after January 1, 2024, if a prescription drug rebate is more than the amount needed to reduce the insured's copayment to zero on a particular drug, the remainder shall be credited to the insurer.
E. Beginning on or after January 1, 2024, any rebate amount shall be counted toward the insured's out-of-pocket prescription drug costs.
F. For purposes of this section, "cost sharing" means any:
(1) copayment;
(2) coinsurance;
(3) deductible;
(4) out-of-pocket maximum;
(5) other financial obligation, other than a premium or share of a premium; or
(6) combination thereof.
G. The provisions of this section do not apply to excepted benefit plans as provided pursuant to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978], catastrophic plans, tax-favored plans or high-deductible health plans with health savings accounts until an eligible insured's deductible has been met, unless otherwise allowed pursuant to federal law.
Laws 2023, ch. 206, § 5.
NMSA 1978, § 59A-46-53 Pharmacy benefits; prescription synchronization
59A-46-53. Pharmacy benefits; prescription synchronization
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides prescription drug benefits shall allow an enrollee to fill or refill a prescription for less than a thirty-day supply of the prescription drug, and apply a prorated daily copayment or coinsurance for the fill or refill, if:
(1) the prescribing practitioner or the pharmacist determines the fill or refill to be in the best interest of the enrollee;
(2) the enrollee requests or agrees to receive less than a thirty-day supply of the prescription drug; and
(3) the reduced fill or refill is made for the purpose of synchronizing the enrollee's prescription drug fills.
B. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides prescription drug benefits shall not:
(1) deny coverage for the filling of a chronic medication when the fill is made in accordance with a plan to synchronize multiple prescriptions for the enrollee pursuant to Subsection A of this section established among the health maintenance organization, the prescribing practitioner and a pharmacist. The health maintenance organization shall allow a pharmacy to override any denial indicating that a prescription is being refilled too soon for the purposes of medication synchronization; and
(2) prorate a dispensing fee to a pharmacy that fills a prescription with less than a thirty-day supply of prescription drug pursuant to Subsection A of this section. The health maintenance organization shall pay in full a dispensing fee for a partially filled or refilled prescription for each prescription dispensed, regardless of any prorated copayment or coinsurance that the enrollee may pay for prescription synchronization services.
Laws 2015, ch. 65, § 5.
NMSA 1978, § 59A-46-54 Provider credentialing; requirements; deadline
59A-46-54. Provider credentialing; requirements; deadline
A. The superintendent shall adopt and promulgate rules to provide for a uniform and efficient provider credentialing process. The superintendent shall approve no more than two forms of application to be used for the credentialing of providers.
B. A carrier shall not require a provider to submit information not required by a credentialing application established pursuant to Subsection A of this section.
C. The provisions of this section apply equally to initial credentialing applications and applications for recredentialing.
D. The rules that the superintendent adopts and promulgates shall require primary credential verification no more frequently than every three years and allow provisional credentialing for a period of one year.
E. Nothing in this section shall be construed to require a carrier to credential or provisionally credential a provider.
F. The rules that the superintendent adopts and promulgates shall establish that a carrier or a carrier's agent shall:
(1) assess and verify the qualifications of a provider applying to become a participating provider within thirty calendar days of receipt of a complete credentialing application and issue a decision in writing to the applicant approving or denying the credentialing application;
(2) be permitted to extend the credentialing period to assess and issue a determination by an additional fifteen calendar days if, upon review of a complete application, it is determined that the circumstance presented, including an admission of sanctions by the state licensing board, investigation or felony conviction, revocation of clinical privileges or denial of insurance coverage, requires additional consideration;
(3) within ten working days after receipt of a credentialing application, send a written notification, via United States certified mail, to the applicant requesting any information or supporting documentation that the carrier requires to approve or deny the credentialing application. The notice to the applicant shall include a complete and detailed description of all of the information or supporting documentation required and the name, address and telephone number of a person who serves as the applicant's point of contact for completing the credentialing application process. Any information required pursuant to this section shall be reasonably related to the information in the application; and
(4) no later than thirty calendar days as described in Paragraph (1) of this subsection or an additional fifteen days as described in Paragraph (2) of this subsection, load into the carrier's provider payment system all provider information, including all information needed to correctly reimburse a newly approved provider according to the provider's contract. The carrier or carrier's agent shall add the approved provider's data to the provider directory upon loading the provider's information into the carrier's provider payment system.
G. A carrier shall reimburse a provider for covered health care services for any claims from the provider that the carrier receives with a date of service more than thirty calendar days after the date on which the carrier received a complete credentialing application for that provider if:
(1) the provider:
(a) has submitted a complete credentialing application and any supporting documentation that the carrier has requested in writing within the time frame established in Paragraph (3) of Subsection F of this section;
(b) has no past or current license sanctions or limitations, as reported by the New Mexico medical board or another pertinent licensing and regulatory agency, or by a similar out-of-state licensing and regulatory entity for a provider licensed in another state; and
(c) has professional liability insurance or is covered under the Medical Malpractice Act; and
(2) the carrier:
(a) has approved, or has failed to approve or deny, the applicant's complete credentialing application within the time frame established pursuant to Paragraph (1) or (2) of Subsection F of this section; or
(b) fails to load the approved applicant's information into the carrier's provider payment system in accordance with Paragraph (4) of Subsection F of this section.
H. A provider who, at the time services were rendered, was not employed by a practice or group that has contracted with the carrier to provide services at specified rates of reimbursement shall be paid by the carrier in accordance with the carrier's standard reimbursement rate.
I. A provider who, at the time services were rendered, was employed by a practice or group that has contracted with the carrier to provide services at specified rates of reimbursement shall be paid by the carrier in accordance with the terms of that contract.
J. The superintendent shall adopt and promulgate rules to provide for the resolution of disputes relating to reimbursement and credentialing arising in cases where credentialing is delayed beyond thirty days after application.
K. A carrier shall reimburse a provider pursuant to Subsections G, H and I of this section until the earlier of the following occurs:
(1) the carrier's approval or denial of the provider's complete credentialing application; or
(2) the passage of three years from the date the carrier received the provider's complete credentialing application.
Laws 2015, ch. 111, § 4; 2016, ch. 20, § 4; 2023, ch. 175, § 3.
NMSA 1978, § 59A-46-55 Coverage exclusion. (Contingent repeal. See note below.)
59A-46-55. Coverage exclusion. (Contingent repeal. See note below.)
Coverage of vasectomy and male condoms pursuant to Section 7 [59A-46-44 NMSA 1978] of this 2019 act is excluded for high-deductible individual or group health maintenance organization contracts with health savings accounts delivered or issued for delivery in this state until an enrollee's deductible has been met.
Laws 2019, ch. 263, § 8.
NMSA 1978, § 59A-46-56 Physical rehabilitation services; limits on cost sharing
59A-46-56. Physical rehabilitation services; limits on cost sharing
A. An individual or group health maintenance contract that is delivered, issued for delivery or renewed in this state shall not impose a member cost share for physical rehabilitation services that is greater than that for primary care services on a coinsurance percentage basis when coinsurance is applied or on an absolute dollar amount when a copay is applied.
B. As used in this section:
(1) "physical rehabilitation services" means services aimed at maximizing an individual's level of function, returning to a prior level of function or maintaining or slowing the decline of function, which services are provided by or under the direction of a licensed physical therapist, occupational therapist or speech therapist; and
(2) "primary care services" means the first level of basic or general health care for a person's health needs, including diagnostic and treatment services, initiation of referrals for other health care services and maintenance of the continuity of care when appropriate.
Laws 2019, ch. 188, § 4.
NMSA 1978, § 59A-46-57 Behavioral health services; elimination of cost sharing
59A-46-57. Behavioral health services; elimination of cost sharing
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that offers coverage of behavioral health services shall not impose cost sharing on those behavioral health services in network.
B. For the purposes of this section:
(1) "behavioral health services" means professional and ancillary services for the treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders, including inpatient, detoxification, residential treatment and partial hospitalization, intensive outpatient therapy, outpatient therapy and all medications, including brand-name pharmacy drugs when generics are unavailable;
(2) "coinsurance" means a cost-sharing method that requires an enrollee to pay a stated percentage of medical expenses after any deductible amount is paid; provided that coinsurance rates may differ for different types of services under the same individual or group health maintenance organization contract;
(3) "copayment" means a cost-sharing method that requires an enrollee to pay a fixed dollar amount when health care services are received, with the carrier paying the balance of the allowable amount; provided that there may be different copayment requirements for different types of services under the same individual or group health maintenance organization contract; and
(4) "cost sharing" means a copayment, coinsurance, deductible or any other form of financial obligation of an enrollee other than a premium or a share of a premium, or any combination of any of these financial obligations, as defined by the terms of an individual or group health maintenance organization contract.
C. The provisions of this section do not apply to excepted benefit plans as provided under the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978], catastrophic plans as defined under 42 USCA Section 18022(e) or high-deductible health plans with health savings accounts until an enrollee's deductible has been met, unless otherwise permitted by federal law.
Laws 2021, ch. 136, § 8; 2025, ch. 115, § 4.
NMSA 1978, § 59A-46-58 Anatomical gift nondiscrimination
59A-46-58. Anatomical gift nondiscrimination
A. As used in this section, "organ transplant" includes parts or the whole of organs, eyes or tissue.
B. A health maintenance organization contract that provides coverage for organ transplants or associated care shall not:
(1) deny coverage for organ transplantation or associated care to an enrollee solely on the basis of the enrollee's physical or mental disability;
(2) deny to an enrollee with a physical or mental disability eligibility or continued eligibility to enroll or to renew enrollment under the terms of the health maintenance organization's benefit policy or plan solely for the purpose of avoiding the requirements of this section;
(3) penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to an enrollee with a disability; or
(4) reduce or limit benefits to an enrollee with a physical or mental disability for associated care related to organ transplantation as determined in consultation with the physician and patient.
Laws 2023, ch. 171, § 5.
NMSA 1978, § 59A-46-59 Chiropractic physician services; limits on cost sharing and coinsurance
59A-46-59. Chiropractic physician services; limits on cost sharing and coinsurance
A. An individual or group health maintenance contract that is delivered, issued for delivery or renewed in this state that offers coverage of the services of a chiropractic physician shall not impose a copayment or coinsurance on those chiropractic physician services that exceeds the copayment or coinsurance imposed for primary care services.
B. As used in this section, "primary care services" means the first level of basic or general health care for a person's health needs, including diagnostic and treatment services, initiation of referrals for other health care services and maintenance of the continuity of care when appropriate.
C. The provisions of this section do not apply to short-term travel, accident-only or limited or specified-disease policies.
Laws 2023, ch. 51, § 4.
NMSA 1978, § 59A-46-60 Sexually transmitted infection care; cost sharing eliminated
59A-46-60. Sexually transmitted infection care; cost sharing eliminated
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that offers coverage for preventive care or treatment of sexually transmitted infections shall not impose cost sharing on eligible enrollees.
B. Pursuant to this section, preventive care or treatment of sexually transmitted infections shall not be conditioned upon the gender identity of the insured.
C. The provisions of Subsection A of this section do not apply to high-deductible health care plans with health savings accounts until an eligible enrollee's deductible has been met, unless otherwise allowed pursuant to federal law.
D. For the purposes of this section:
(1) "cost sharing" means policy deductibles, copayments or coinsurance;
(2) "preventive care" means screening, testing, examination or counseling and the administration, dispensing or prescribing of preventive drugs, devices or supplies incidental to the prevention of a sexually transmitted infection;
(3) "sexually transmitted infection" means chlamydia, syphilis, gonorrhea, HIV and relevant types of hepatitis, as well as any other sexually transmitted infection regardless of mode of transportation, as designated by rule upon making a finding that the particular sexually transmitted infection is contagious; and
(4) "treatment" means medically necessary care for the management of an existing sexually transmitted infection.
Laws 2023, ch. 99, § 4.
NMSA 1978, § 59A-46-61 Definitions
59A-46-61. Definitions
As used in Sections 25 through 33 [59A-46-61 to 59A-46-69 NMSA 1978] of this 2023 act:
A. "generally recognized standards" means standards of care and clinical practice established by evidence-based sources, including clinical practice guidelines and recommendations from mental health and substance use disorder care provider professional associations and relevant federal government agencies, that are generally recognized by providers practicing in relevant clinical specialties, including:
(1) psychiatry;
(2) psychology;
(3) social work;
(4) clinical counseling;
(5) addiction medicine and counseling; or
(6) family and marriage counseling; and
B. "mental health or substance use disorder services" means:
(1) professional services, including inpatient and outpatient services and prescription drugs, provided in accordance with generally recognized standards of care for the identification, prevention, treatment, minimization of progression, habilitation and rehabilitation of conditions or disorders listed in the current edition of the American psychiatric association's Diagnostic and Statistical Manual of Mental Disorders, including substance use disorder; or
(2) professional talk therapy services, provided in accordance with generally recognized standards of care, provided by a marriage and family therapist licensed pursuant to the Counseling and Therapy Practice Act [Chapter 61, Article 9A NMSA 1978].
Laws 2023, ch. 114, § 25.
NMSA 1978, § 59A-46-62 Benefits required
59A-46-62. Benefits required
A health maintenance organization, other than a small group health maintenance organization contract that is delivered, issued for delivery or renewed in this state, shall provide coverage for all mental health or substance use disorder services required by generally recognized standards of care.
Laws 2023, ch. 114, § 26.
NMSA 1978, § 59A-46-63 Parity for coverage of mental health or substance use disorder services
59A-46-63. Parity for coverage of mental health or substance use disorder services
A. The office of superintendent of insurance shall ensure that a carrier complies with federal and state laws, rules and regulations applicable to coverage for mental health or substance use disorder services.
B. A carrier shall not impose quantitative treatment limitations, financial restrictions, limitations or requirements on the provision of mental health or substance use disorder services that are more restrictive than the predominant restrictions, limitations or requirements that are imposed on substantially all of the coverage of benefits for other conditions.
C. A carrier shall not impose non-quantitative treatment limitations for the treatment of mental health or substance use disorders or conditions unless factors, including the processes, strategies or evidentiary standards used in applying the non-quantitative treatment limitation, as written and in operation, are comparable to and are applied no more restrictively than the factors used in applying the limitation with respect to medical or surgical benefits in the classification.
Laws 2023, ch. 114, § 27.
NMSA 1978, § 59A-46-64 Provider network adequacy
59A-46-64. Provider network adequacy
A. A carrier shall maintain an adequate provider network to provide mental health or substance use disorder services.
B. The superintendent shall ensure access to mental health or substance use disorder services providers, including parity with medical and surgical services provider access, through regulation and review of claims processing, provider reimbursement procedures, network adequacy and provider reimbursement rate adequacy.
C. A carrier shall ensure that the process by which reimbursement rates for mental health and substance use disorder services are determined is comparable to and no more stringent than the process for reimbursement of medical or surgical benefits. In developing provider reimbursement rates, a carrier shall demonstrate that it has performed a comparability analysis of provider:
(1) reimbursement rates in surrounding states;
(2) reimbursement rates between mental health and substance use disorder providers and medical or surgical providers; and
(3) credentialing processes for mental health and substance use disorder providers and medical or surgical providers.
D. A carrier shall undertake all efforts, including increasing provider reimbursement rates through the processes and strategies described in Subsection C of this section, to ensure state-mandated network adequacy for the provision of mental health or substance use disorder services.
E. When in-network access to mental health or substance use disorder services are not reasonably available, a carrier shall provide access to out-of-network services with the same cost-sharing obligations to an enrollee as those required for in-network services.
Laws 2023, ch. 114, § 28.
NMSA 1978, § 59A-46-65 Utilization review of mental health or substance use disorder services
59A-46-65. Utilization review of mental health or substance use disorder services
A. A carrier shall, at least monthly, review and update the carrier's utilization review process to reflect the most recent evidence and generally recognized standards of care.
B. When performing a utilization review of mental health or substance use disorder services, including level of care placement, continued stay, transfer and discharge, a carrier shall apply criteria in accordance with generally recognized standards of care.
C. A carrier shall provide utilization review training to staff and contractors undertaking activities related to utilization review.
D. A carrier shall:
(1) develop utilization review policies regarding quantitative and non-quantitative limitations for mental health or substance use disorder services coverage that are no more restrictive than the utilization review policies regarding quantitative and non-quantitative limitations for medical and surgical care; and
(2) make utilization review policies available to providers or enrollees.
Laws 2023, ch. 114, § 29.
NMSA 1978, § 59A-46-66 Prohibited exclusions of coverage for mental health or substance use disorder services
59A-46-66. Prohibited exclusions of coverage for mental health or substance use disorder services
A carrier shall not exclude provider prescribed coverage for mental health or substance use disorder services otherwise included in its coverage when:
A. it is available pursuant to federal or state law for individuals with disabilities;
B. it is otherwise ordered by a court or administrative agency;
C. it is available to an enrollee through a public benefit program; or
D. an enrollee has a concurrent diagnosis.
Laws 2023, ch. 114, § 30.
NMSA 1978, § 59A-46-67 Level of care determinations for the provision of mental health or substance use disorder services
59A-46-67. Level of care determinations for the provision of mental health or substance use disorder services
A. A carrier shall provide coverage for all in-network mental health or substance use disorder services, consistent with generally recognized standards of care, including placing an enrollee into a medically necessary level of care.
B. Changes in level and duration of care shall be determined by the enrollee's provider in consultation with the carrier.
C. Level of care determinations shall include placement of an enrollee into a facility that provides detoxification services, a hospital, an inpatient rehabilitation treatment facility or an outpatient treatment program.
D. Level of care services for an enrollee with a mental health or substance use disorder shall be based on the mental health or substance use disorder needs of the enrollee rather than arbitrary time limits.
Laws 2023, ch. 114, § 31.
NMSA 1978, § 59A-46-68 Coordination of care
59A-46-68. Coordination of care
At the request of an enrollee, a carrier may facilitate communication between mental health or substance use disorder services providers and the enrollee's designated primary care provider to ensure coordination of care to prevent any conflicts of care that could be harmful to the enrollee.
Laws 2023, ch. 114, § 32.
NMSA 1978, § 59A-46-69 Confidentiality provisions
59A-46-69. Confidentiality provisions
A carrier shall protect the confidentiality of an enrollee receiving mental health or substance use disorder treatment.
Laws 2023, ch. 114, § 33.
NMSA 1978, § 59A-46-70 Exceptions
59A-46-70. Exceptions
The provisions of Sections 25 through 33 [59A-46-61 to 59A-46-69 NMSA 1978] of this 2023 act do not apply to short-term plans subject to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978].
Laws 2023, ch. 114, § 34.
NMSA 1978, § 59A-46-71 Biomarker testing coverage
59A-46-71. Biomarker testing coverage
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state shall provide coverage for eligible enrollees to receive biomarker testing.
B. Coverage provided pursuant to this section shall be for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including:
(1) labeled indications for a United States food and drug administration-approved or -cleared test;
(2) indicated tests for a United States food and drug administration-approved drug;
(3) warnings and precautions on United States food and drug administration labels;
(4) federal centers for medicare and medicaid services national coverage determinations or medicare administrative contractor local coverage determinations; or
(5) nationally recognized clinical practice guidelines.
C. A health maintenance organization contract providing coverage for biomarker testing pursuant to this section shall ensure that:
(1) coverage is provided in a manner that limits disruptions in care, including coverage for multiple biopsies or biospecimen samples; and
(2) a patient and a practitioner who prescribes biomarker testing have clear, accessible and convenient processes to request an appeal of a benefit denial by the carrier and that those processes are accessible on the carrier's website.
D. Coverage for biomarker testing may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract.
E. The provisions of this section do not apply to accident-only or limited or specified disease policies, plans or certificates of health insurance.
F. As used in this section:
(1) "biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. "Biomarker" includes gene mutations, characteristics of genes or protein expression;
(2) "biomarker testing" means analysis of a patient's tissue, blood or other biospecimen for the presence of a biomarker and includes single-analyte tests, multi-plex panel tests, protein expression and whole exome, whole genome and whole transcriptome sequencing; and
(3) "nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines that are:
(a) developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and with a conflict-of-interest policy; and
(b) used to establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.
Laws 2023, ch. 138, § 5.
NMSA 1978, § 59A-46-72 Medical necessity and nondiscrimination standards for coverage of prosthetic devices, custom orthotic devices or complex rehabilitation technology devices
59A-46-72. Medical necessity and nondiscrimination standards for coverage of prosthetic devices, custom orthotic devices or complex rehabilitation technology devices
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that covers essential health benefits and covers prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall consider these benefits habilitative or rehabilitative benefits for purposes of state or federal requirements on essential health benefits coverage.
B. When performing a utilization review for a request for coverage of prosthetic device, custom orthotic device or complex rehabilitation technology device benefits, a health maintenance organization shall apply the most recent version of evidence-based treatment and fit criteria as recognized by relevant clinical specialists or their organizations. Such standards may be named by the superintendent in rule.
C. A health maintenance organization shall render utilization review determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices, custom orthotic devices or complex rehabilitation technology devices, solely based on an enrollee's actual or perceived disability.
D. A health maintenance organization shall not deny a prosthetic device, a custom orthotic device or a complex rehabilitation technology device benefit for a person with limb loss, limb absence or mobility limitation that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
E. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that offers coverage for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall include language describing an enrollee's rights pursuant to Subsections C and D of this section in its evidence of coverage and any benefit denial letters.
F. Prosthetic device, custom orthotic device or complex rehabilitation technology device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. An individual or group health maintenance organization contract may impose cost sharing on prosthetic devices, custom orthotic devices or complex rehabilitation technology devices; provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan's coverage for inpatient physician and surgical services.
G. An individual or group health maintenance organization contract that provides coverage for services related to prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall ensure access to medically necessary clinical care and to prosthetic devices, custom orthotic devices or complex rehabilitation technology devices and technology from not less than two distinct prosthetic device, custom orthotic device or complex rehabilitation technology device providers in the managed care plan's provider network located in the state. In the event that medically necessary covered prosthetic devices, custom orthotic devices or complex rehabilitation technology devices are not available from an in-network provider, the health maintenance organization shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost sharing determined on an in-network basis.
H. If coverage for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices is provided, payment shall be made for the replacement of a prosthetic device, a custom orthotic device or a complex rehabilitation technology device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary because of any of the following:
(1) a change in the physiological condition of the patient;
(2) an irreparable change in the condition of the device or in a part of the device; or
(3) the condition of the device or the part of the device requires repairs, and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
I. Covered benefits for prosthetic devices and custom orthotic devices shall provide for more than one prosthetic device or custom orthotic device when medically necessary, but shall include no more than three prosthetic devices or custom orthotic devices per affected limb per covered person; provided that if after three years, a prosthetic device or custom orthotic device is no longer the appropriate device to meet the enrollee's needs for the enrollee's preferred physical activity, coverage and payment for new or replacement devices shall not be limited to three prosthetic or custom orthotic devices per affected limb per covered person. An individual or group health maintenance organization contract shall cover:
(1) the most appropriate prosthetic device or custom orthotic device determined to be medically necessary by the enrollee's treating physician and associated medical providers to restore or maintain the ability to complete activities of daily living or essential job-related activities. This coverage shall include all services and supplies necessary for the effective use of a prosthetic device or a custom orthotic device, including:
(a) formulation of the device's design, fabrication, material and component selection, measurements, fittings and static and dynamic alignments;
(b) all materials and components necessary to use the device;
(c) instructing the enrollee in the use of the device; and
(d) the repair and replacement of the device;
(2) a prosthetic device or a custom orthotic device determined by the enrollee's provider to be the most appropriate model that meets the medical needs of the enrollee for performing physical activities, including running, biking and swimming, and to maximize the enrollee's upper limb function. This coverage shall include all services and supplies necessary for the effective use of a prosthetic device or a custom orthotic device, including:
(a) formulation of the device's design, fabrication, material and component selection, measurements, fittings and static and dynamic alignments;
(b) all materials and components necessary to use the device;
(c) instructing the enrollee in the use of the device; and
(d) the repair and replacement of the device; and
(3) a prosthetic device or custom orthotic device determined by the enrollee's prosthetic or orthotic care provider to be the most appropriate prosthetic device or custom orthotic device that meets the medical needs of the enrollee for purposes of showering or bathing.
J. Coverage for complex rehabilitation technology devices shall be based on an enrollee's specific medical, physical, functional and environmental needs and capacities to engage in normal life activities and shall allow an enrollee to obtain more than one complex rehabilitation technology device, but no more than two complex rehabilitation technology devices per covered person; provided that if after three years, a complex rehabilitation technology device is no longer the appropriate device to meet the enrollee's needs for the enrollee's preferred physical activity, coverage and payment for new or replacement devices shall not be limited to two complex rehabilitation technology devices per covered person. An individual or group health maintenance organization contract shall cover:
(1) complex rehabilitation technology devices for daily use that meets the enrollee's mobility and positioning needs;
(2) complex rehabilitation technology devices to enable the enrollee to participate in physical activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for the effective use of a complex rehabilitation technology device, including:
(a) configuring, fitting, programming, adjusting or adapting the particular device for use by a person, including the formulation of the device's design, fabrication, material and component selection and measurements;
(b) all materials and components necessary to use the device;
(c) instructing the enrollee in the use of the device; and
(d) the repair and replacement of the device.
K. A complex rehabilitation technology device that is a manual or power wheelchair shall only be covered pursuant to this section if the:
(1) enrollee has undergone a complex rehabilitation technology device evaluation conducted by a licensed physical therapist or occupational therapist who has no financial relationship with the supplier of the complex rehabilitation technology device; and
(2) complex rehabilitation technology device is provided by a complex rehabilitation technology device supplier that:
(a) employs at least one assistive technology professional certified by the rehabilitation engineering and assistive technology society of North America who specialized in seating, positioning and mobility and has direct, in-person involvement in the wheelchair selection for the enrollee; and
(b) makes at least one qualified complex rehabilitation technology device service technician available in each service area served by the supplier to service and repair devices that are furnished by the supplier.
L. Confirmation from a prescribing health care provider may be required if the prosthetic device, custom orthotic device or complex rehabilitation technology device or part being replaced is less than three years old.
M. The provisions of this section do not apply to excepted benefits plans subject to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978].
N. As used in this section, "complex rehabilitation technology device" means a subset of durable medical equipment that:
(1) consists of complex rehabilitation manual and power wheelchairs and mobility devices, including specialized seating and positioning items, options and accessories;
(2) is designed, manufactured, configured, adjusted or modified for a specific person to meet that person's unique medical, physical, functional and environmental needs and capacities;
(3) is generally not useful to a person in the absence of a disability, illness, injury or other medical condition; and
(4) requires specialized services to ensure appropriate use of the item, including:
(a) an evaluation of the features and functions necessary to assist the person who will use the device; or
(b) configuring, fitting, programming, adjusting or adapting the particular device for use by a person.
Laws 2023, ch. 196, § 5; 2026, ch. 41, § 5.
Source: New Mexico Compilation Commission (nmonesource.com)URL: https://nmonesource.com/nmos/nmsa-unanno/en/item/18562/index.doFetched: 10/20/2026