reglab/statecodes huggingface dataset:
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-47 - Coverage of colorectal cancer screening.

A. An individual or group health insurance policy, health care plan and certificate of health insurance 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.
C. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified-disease policies.
History:
Laws 2007, ch. 17, § 1.
ANNOTATIONS
Effective dates.
— Laws 2007, ch. 17, contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 15, 2007, 90 days after the adjournment of the legislature.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-48 - General anesthesia and hospitalization for dental surgery.

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is 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.
History:
Laws 2007, ch. 218, § 2.
ANNOTATIONS
Effective dates.
— Laws 2007, ch. 218, § 6 made Laws 2007, ch. 218, § 2 effective July 1, 2007.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-49.1 - Coverage for orally administered anticancer medications; limits on patient costs.

A. An individual or group health insurance policy, health care plan or certificate of health insurance 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. An insurer 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, "insurer" or "health plan":
(1) means:
(a) a health insurer;
(b) a nonprofit health service provider;
(c) a health maintenance organization;
(d) a managed care organization; or
(e) a provider service 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.
History:
Laws 2011, ch. 55, § 2.
ANNOTATIONS
Effective dates.
— Laws 2011, ch. 55, § 7 made Laws 2011, ch. 55, § 2 effective June 17, 2011.
Applicability.
— Laws 2011, ch. 55, § 6 provided that the provisions of this act apply to insurance policies that provide coverage for cancer treatment and that are delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2012.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-49.2 - Coverage of prescription eye drop refills.

A. An individual or group health insurance policy, health care plan or certificate of health insurance 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.
History:
Laws 2012, ch. 27, § 2.
ANNOTATIONS
Effective dates.
— Laws 2012, ch. 27, § 7 made Laws 2012, ch. 27, § 2 effective January 1, 2013.
Applicability.
— Laws 2012, ch. 27, § 6 provided that the provisions of Laws 2012, ch. 27, §§ 1 to 5 apply to insurance policies that provide coverage for prescription eye drops and that are delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2013.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-51 - Dental insurance plan; dental fees not covered; severability.

A. As used in this section:
(1) "covered services" means dental care services for which a reimbursement is available under an enrollee's plan contract or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments or any other limitation; and
(2) "dental insurance plan" means any policy of insurance that is issued by a health care service contractor that provides for coverage of dental services not in connection with a medical plan.
B. No contract of any health care service contractor that covers any dental services and no contract or participating provider agreement with a dentist shall require, directly or indirectly, that a dentist who is a participating provider provide services to an enrolled participant at a fee set by, or at a fee subject to the approval of, the health care service contractor unless the dental services are covered services.
C. A health care service contractor or other person providing third party administrator services shall not make available any providers in its dentist network to a plan that sets dental fees for any services except covered services.
D. If any part or application of this section is held invalid, the remainder or its application to other situations or persons shall not be affected.
History:
Laws 2011, ch. 128, § 1.
ANNOTATIONS
Emergency clauses.
— Laws 2011, ch. 128, § 2 contained an emergency clause and was approved April 7, 2011.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-52 - Prescription drug prior authorization protocols.

A. After January 1, 2014, a health insurer 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 insurer 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 insurer":
(1) means:
(a) a health insurer;
(b) a nonprofit health service provider;
(c) a health maintenance organization;
(d) a managed care organization; or
(e) a provider service 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 insurer has delegated financial risk for prescription drugs and that does not use a prior authorization process for prescription drugs; or
(c) a health insurer or its affiliated providers if the health insurer owns and operates its pharmacies and does not use a prior authorization process for prescription drugs.
History:
Laws 2013, ch. 170 , § 5.
ANNOTATIONS
Effective dates.
— Laws 2013, ch. 170 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2013, 90 days after the adjournment of the legislature.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-53 - Pharmacy benefits; prescription synchronization.

A. An individual health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state and that provides a prescription drug benefit shall allow an insured 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 insured;
(2) the insured 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 insured's prescription drug fills.
B. An individual health insurance policy, health care plan or certificate of health insurance that offers a prescription drug benefit 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 insured pursuant to Subsection A of this section established among the insurer, the prescribing practitioner and a pharmacist. The insurer 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 insurer 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 insured may pay for prescription synchronization services.
History:
Laws 2015, ch. 65, § 3.
ANNOTATIONS
Effective dates.
— Laws 2015, ch. 65 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 19, 2015, 90 days after the adjournment of the legislature.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-53.2 - Pharmacist prescriptive authority services; reimbursement parity.

An insurer 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 a health insurance plan, policy or certificate of health insurance at the standard contracted rate that the health insurance policy, health care plan or certificate of health insurance reimburses, for the same service pursuant to that policy, plan or certificate, 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].
History:
Laws 2020, ch. 58, § 3; 2021, ch. 54, § 11.
ANNOTATIONS
The 2021 amendment,
effective June 18, 2021, after "Medical Practice Act", deleted "or the Osteopathic Medicine Act".
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-53.3 - Calculating an insured's cost-sharing obligation for prescription drug coverage.

A. When calculating an insured's cost-sharing obligation for covered prescription drugs, pursuant to an individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state, the insurer shall credit the insured 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.
History:
Laws 2023, ch. 206, § 3.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 206 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-55 - Coverage exclusion. (Contingent repeal. See note.)

Coverage of vasectomy and male condoms pursuant to Section 3 [59A-22-42 NMSA 1978] of this 2019 act is excluded for high-deductible individual and group health insurance policies, health care plans or certificates of insurance with health savings accounts delivered or issued for delivery in this state until an insured's deductible has been met.
History:
Laws 2019, ch. 263, § 4.
ANNOTATIONS
Contingent repeal.
— Laws 2019, ch. 263, § 11 provided that upon certification by the superintendent of insurance to the director of the legislative council service and the New Mexico compilation commission that federal law permits coverage of vasectomies and male condoms under high-deductible health benefits plans with health savings accounts, Sections 4, 6, 8 and 10 of this 2019 act [59A-22-55, 59A-23-7.15, 59A-46-55 and 59A-47-45.6] are repealed.
Effective dates.
— Laws 2019, ch. 263 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2019, 90 days after the adjournment of the legislature.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-56 - Physical rehabilitation services; limits on cost sharing.

A. An individual or group health insurance policy, health care plan or certificate of health insurance 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.
History:
Laws 2019, ch. 188, § 2.
ANNOTATIONS
Effective dates.
— Laws 2019, ch. 188, § 6 made Laws 2019, ch. 188 effective January 1, 2020.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-57 - Behavioral health services; elimination of cost sharing.

A. Until January 1, 2027, an individual or group health insurance policy, health care plan or certificate of health insurance 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.
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 and all medications, including brand-name pharmacy drugs when generics are unavailable;
(2) "coinsurance" means a cost-sharing method that requires the insured 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 insurance policy, health care plan or certificate of health insurance;
(3) "copayment" means a cost-sharing method that requires the insured to pay a fixed dollar amount when health care services are received, with the insurer 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 insurance policy, health care plan or certificate of health insurance; and
(4) "cost sharing" means a copayment, coinsurance, deductible or any other form of financial obligation of the insured 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 insurance policy, health care plan or certificate of health insurance.
History:
Laws 2021, ch. 136, § 6.
ANNOTATIONS
Effective dates.
— Laws 2021, ch. 136, § 11 made Laws 2021, ch. 136, § 6 effective January 1, 2022.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-58 - Anatomical gift nondiscrimination.

A. For purposes of this section:
(1) "covered person" means a policyholder or other person covered by a health benefit plan; and
(2) "organ transplant" includes parts or the whole of organs, eyes or tissue.
B. All individual and group health insurance policies delivered or issued for delivery in this state that provide coverage for organ transplants and associated care shall not:
(1) deny that coverage solely on the basis of a covered person's physical or mental disability;
(2) deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health 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 a covered person with a physical or mental disability; or
(4) reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient.
History:
Laws 2023, ch. 171, § 3.
ANNOTATIONS
Emergency clauses.
— Laws 2023, ch. 171, § 7 contained an emergency clause and was approved April 5, 2023.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-59 - Chiropractic physician services; limits on cost sharing and coinsurance. (Effective January 1, 2024.)

A. An individual or group health insurance policy, health care plan or certificate of health insurance 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.
History:
Laws 2023, ch. 51, § 2.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 51, § 6 made Laws 2023, ch. 51, § 2 effective January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22 - Health Insurance Contracts › Section 59A-22-60 - Sexually transmitted infection care; cost sharing eliminated.

A. An individual or group health insurance policy, health care plan or certificate of health insurance 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 insureds.
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 insured'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.
History:
Laws 2023, ch. 99, § 2.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 99 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
Applicability.
— Laws 2023, ch. 99, § 7 provided that the provisions of Laws 2023, ch. 99 apply to health insurance policies, health care plans, certificates of health insurance or health maintenance organization contracts that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-1 - Short title.

Chapter 59A, Article 22A NMSA 1978 shall be known and may be cited as the "Preferred Provider Arrangements Law".
History:
1978 Comp., § 59A-22A-1, enacted by Laws 1993, ch. 320, § 59.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-2 - Purpose.

The purpose of the Preferred Provider Arrangements Law is to encourage health care cost containment while preserving quality of care by allowing health care insurers to enter into preferred provider arrangements in accordance with minimum standards for preferred provider arrangements and for the health benefit plans associated with those arrangements.
History:
1978 Comp., § 59A-22A-2, enacted by Laws 1993, ch. 320, § 60.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-3 - Definitions.

As used in the Preferred Provider Arrangements Law:
A. "covered person" means any person on whose behalf the health care insurer is obligated to pay for or to provide health benefit services;
B. "covered services" means health care services which the health care insurer is obligated to pay for or to provide under a health benefit plan;
C. "emergency care" means health care procedures, treatments or services delivered to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in jeopardy to a person's health, serious impairment of bodily functions, serious dysfunction of a bodily organ or part or disfigurement to a person;
D. "health benefit plan" means the health insurance policy or subscriber agreement between the covered person or the policyholder and the health care insurer that defines the covered services and benefit levels available;
E. "health care insurer" means any person who provides health insurance in this state. For the purposes of the Small Group Rate and Renewability Act [Chapter 59A, Article 23C NMSA 1978], "carrier" or "insurer" includes a licensed insurance company, a licensed fraternal benefit society, a prepaid hospital or medical service plan, a health maintenance organization, a nonprofit health care organization, a multiple employer welfare arrangement or any other person providing a plan of health insurance subject to state insurance regulation;
F. "health care provider" means providers of health care services licensed as required in this state;
G. "health care services" means services rendered or products sold by a health care provider within the scope of the provider's license. The term includes hospital, medical, surgical, dental, vision and pharmaceutical services or products;
H. "preferred provider" means a health care provider or group of providers who have contracted with a health care insurer to provide specified covered services to a covered person; and
I. "preferred provider arrangement" means a contract between or on behalf of the health care insurer and a preferred provider that complies with all the requirements of the Preferred Provider Arrangements Law.
History:
1978 Comp., § 59A-22A-3, enacted by Laws 1993, ch. 320, § 61; 2021, ch. 108, § 22.
ANNOTATIONS
The 2021 amendment,
effective July 1, 2021, revised the definition of "emergency care"; and in Subsection C, after "'emergency care' means", complete rewrote the remainder of the subsection.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-4 - Preferred provider arrangements.

Notwithstanding any provisions of law to contrary, any health care insurer may enter into preferred provider arrangements.
A. Such arrangements shall:
(1) establish the amount and manner of payment to the preferred provider. Such amount and manner of payment may include capitation payments for preferred providers;
(2) include mechanisms which are designed to minimize the cost of the health benefit plan; for example:
(a) the review or control of utilization of health care services; or
(b) procedures for determining whether health care services rendered are medically necessary; and
(3) assure reasonable access to covered services available under the preferred provider arrangement and an adequate number of preferred providers to render those services.
B. Such arrangements shall not unfairly deny health benefits for medically necessary covered services.
C. If an entity enters into a contract providing covered services with a health care provider, but is not engaged in activities which would require it to be licensed as a health care insurer, such entity shall file with the superintendent information describing its activities, a description of the contract or agreement it has entered into with the health care providers, and such other information as is required by the provisions of the Health Care Benefits Jurisdiction Act [59A-15-14 to 59A-15-19 NMSA 1978] and any regulations promulgated under its authority. Employers who enter into contracts with health care providers for the exclusive benefit of their employees and dependents are subject to the Health Care Benefits Jurisdiction Act and are exempt from this requirement only to the extent required by federal law.
History:
1978 Comp., § 59A-22A-4, enacted by Laws 1993, ch. 320, § 62.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-5 - Health benefit plans.

A. Health care insurers may issue health benefit plans which provide for incentives for covered persons to use the health care services of preferred providers. Such policies or subscriber agreement shall contain at least the following provisions:
(1) a provision that if a covered person receives emergency care for services specified in the preferred provider arrangement and cannot reasonably reach a preferred provider that emergency care rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider; and
(2) a provision which clearly identifies the differentials in benefit levels for health care services of preferred providers and benefit levels for health care services of non-preferred providers.
B. If a health benefit plan provides differences in benefit levels payable to preferred providers compared to other providers, such differences shall not unfairly deny payment for covered services and shall be no greater than necessary to provide a reasonable incentive for covered persons to use the preferred provider.
History:
1978 Comp., § 59A-22A-5, enacted by Laws 1993, ch. 320, § 63.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-6 - Preferred provider participation requirements.

Health care insurers may place reasonable limits on the number or classes of preferred providers which satisfy the standards set forth by the health care insurer, provided that there is no discrimination against providers on the basis of religion, race, color, national origin, age, sex or marital status, and further provided that selection of preferred providers is primarily based on, but not limited to, cost and availability of covered services and the quality of services performed by the providers.
History:
1978 Comp., § 59A-22A-6, enacted by Laws 1993, ch. 320, § 64.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22A - Preferred Provider Arrangements › Section 59A-22A-7 - General requirements.

Health care insurers complying with the Preferred Provider Arrangements Law shall be subject to and are required to comply with all other applicable laws, rules and regulations of this state.
History:
1978 Comp., § 59A-22A-7, enacted by Laws 1993, ch. 320, § 65.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-1 - Short title.

Sections 3 through 7 [59A-22B-1 to 59A-22B-5 NMSA 1978] of this act may be cited as the "Prior Authorization Act".
History:
Laws 2019, ch. 187, § 3.
ANNOTATIONS
Compiler's notes.
— Laws 2019, ch. 187, § 3 was not enacted as part of the Insurance Code, but was compiled there for the convenience of the user.
Effective dates.
— Laws 2019, ch. 187 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2019, 90 days after the adjournment of the legislature.
Applicability.
— Laws 2019, ch. 187, § 8 provided that the provisions of the Prior Authorization Act apply to an individual or group policy contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer on or after July 1, 2019, pursuant to any of the following:
A. Chapter 59A, Article 22 NMSA 1978;
B. Chapter 59A, Article 23 NMSA 1978;
C. the Health Maintenance Organization Law;
D. the Nonprofit Health Care Plan Law; or
E. the Health Care Purchasing Act.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-3 - Emergency care.

Emergency care provided to a covered person, regardless of where the emergency care is provided, shall not be subject to prior authorization requirements.
History:
Laws 2019, ch. 187, § 5.
ANNOTATIONS
Compiler's notes.
— Laws 2019, ch. 187, § 5 was not enacted as part of the Insurance Code, but was compiled there for the convenience of the user.
Effective dates.
— Laws 2019, ch. 187 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2019, 90 days after the adjournment of the legislature.
Applicability.
— Laws 2019, ch. 187, § 8 provided that the provisions of the Prior Authorization Act apply to an individual or group policy contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer on or after July 1, 2019, pursuant to any of the following:
A. Chapter 59A, Article 22 NMSA 1978;
B. Chapter 59A, Article 23 NMSA 1978;
C. the Health Maintenance Organization Law;
D. the Nonprofit Health Care Plan Law; or
E. the Health Care Purchasing Act.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-4 - Duties of office; prescribing penalties.

A. The office shall standardize and streamline the prior authorization process across all health insurers.
B. On or before September 1, 2019, the office shall, in collaboration with health insurers and health care providers, promulgate a uniform prior authorization form for medical care, pharmaceutical benefits or related benefits to be used by every health insurer and health care provider after January 1, 2020; provided that the uniform prior authorization form shall conform to the requirements established for medicare and medicaid medical and pharmacy prior authorization requests.
C. The office shall maintain a log of complaints against health insurers for failure to comply with the Prior Authorization Act. After two warnings issued by the superintendent of insurance, the office may levy a fine of not more than five thousand dollars ($5,000) on a health insurer that fails to comply with the provisions of the Prior Authorization Act.
D. By September 1, 2019, and each September 1 thereafter, the office shall provide an annual written report to the governor and the legislature to include, at a minimum:
(1) prior authorization data for each health insurer individually and for health insurers collectively;
(2) the number and nature of complaints against individual health insurers for failure to follow the Prior Authorization Act; and
(3) actions taken by the office, including the imposition of fines, against individual health insurers to enforce compliance with the Prior Authorization Act.
E. The annual written report shall be posted on the office's website.
History:
Laws 2019, ch. 187, § 6.
ANNOTATIONS
Compiler's notes.
— Laws 2019, ch. 187, § 6 was not enacted as part of the Insurance Code, but was compiled there for the convenience of the user.
Effective dates.
— Laws 2019, ch. 187 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2019, 90 days after the adjournment of the legislature.
Applicability.
— Laws 2019, ch. 187, § 8 provided that the provisions of the Prior Authorization Act apply to an individual or group policy contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer on or after July 1, 2019, pursuant to any of the following:
A. Chapter 59A, Article 22 NMSA 1978;
B. Chapter 59A, Article 23 NMSA 1978;
C. the Health Maintenance Organization Law;
D. the Nonprofit Health Care Plan Law; or
E. the Health Care Purchasing Act.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-6 - Prior authorization rescinding or modifying prohibited.

A health insurer shall not rescind or modify an authorization for mental health or substance use disorder services that has been authorized, after the provider renders the services pursuant to a determination of medical necessity, in good faith, except for cases of fraud or violation of the provider's contract with the health insurer.
History:
Laws 2023, ch. 114, § 11.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 114 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
Applicability.
— Laws 2023, ch. 114, § 46 provided that the provisions of Laws 2023, ch. 114 are applicable to group health insurance policies, health care plans or certificates of health insurance, other than small group health plans, that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-7 - Prior authorization or referral requirement for in-network mental health or substance use disorder services coverage prohibited.

A. A health insurer shall not require prior authorization and referral requirements for the following mental health or substance use disorder services:
(1) acute or immediately necessary care;
(2) acute episodes of chronic mental health or substance use disorder conditions; or
(3) initial in-network inpatient or outpatient substance use treatment services.
B. Prior authorization shall be determined in consultation with the insured's mental health or substance use disorder services provider for:
(1) continuation of services in chronic or stable conditions; or
(2) additional services.
C. Except in cases in which the insured terminates a plan, a health insurer shall not terminate coverage of services without consultation with the insured's mental health or substance use disorder services provider.
D. A health insurer shall not limit coverage for mental health or substance use disorder services up to the point of relief of presenting signs and symptoms or to short-term care or acute treatment.
E. The duration of coverage for an insured with a mental health or substance use disorder shall be based on the mental health or substance use disorder needs of the insured rather than on arbitrary time limits.
F. A health insurer may require a mental health or substance use disorder services provider to provide notification to the health insurer after the initiation of in-network mental health or substance use disorder treatment pursuant to Subsection A of this section.
G. If a provider fails to notify a health insurer pursuant to Subsection F of this section, a health insurer may perform appropriate utilization review.
H. A health insurer may require a mental health or substance use disorder services provider to develop and submit a treatment plan for an insured receiving in-network services in a manner that is compliant with federal law.
History:
Laws 2023, ch. 114, § 12.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 114 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
Applicability.
— Laws 2023, ch. 114, § 46 provided that the provisions of Laws 2023, ch. 114 are applicable to group health insurance policies, health care plans or certificates of health insurance, other than small group health plans, that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 22B - Prior Authorization › Section 59A-22B-8 - Prior authorization for prescription drugs or step therapy for substance use disorder prohibited.

A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of a substance use disorder, pursuant to a medical necessity determination, shall not be subject to prior authorization, except in cases in which a generic version is available.
B. A health insurer shall not impose step therapy requirements before authorizing coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of a substance use disorder, pursuant to a medical necessity determination, except in cases in which a generic version is available.
History:
Laws 2023, ch. 114, § 13.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 114 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
Applicability.
— Laws 2023, ch. 114, § 46 provided that the provisions of Laws 2023, ch. 114 are applicable to group health insurance policies, health care plans or certificates of health insurance, other than small group health plans, that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 23 - Group and Blanket Health Insurance Contracts › Section 59A-23-1 - Scope of article.

This article [Chapter 59A, Article 23 NMSA 1978] shall apply only as to group health insurance contracts and blanket health insurance contracts as hereinafter defined.
History:
Laws 1984, ch. 127, § 460.
ANNOTATIONS
Am. Jur. 2d, A.L.R. and C.J.S. references. —
44 Am. Jur. 2d Insurance §§ 1842 to 1870.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 23 - Group and Blanket Health Insurance Contracts › Section 59A-23-2 - Blanket health insurance.

A. Blanket health insurance is declared to be that form of health insurance covering special groups of not fewer than ten persons as enumerated in one of the following paragraphs:
(1) under a policy or contract issued to a common carrier, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on the common carrier;
(2) under a policy or contract issued to an employer that shall be deemed the policyholder, covering a group of employees defined by reference to exceptional hazards incident to employment;
(3) under a policy or contract issued to a college, school or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder, covering students and teachers;
(4) under a policy or contract issued in the name of a volunteer fire department or first aid or other such volunteer group, which shall be deemed the policyholder, covering all of the members of the department or group; or
(5) under a policy or contract issued to any other substantially similar group that, in the discretion of the superintendent, may be subject to the issuance of a blanket health policy or contract.
B. An individual application shall not be required from a person covered under a blanket sickness or accident policy or contract.
C. All benefits under any blanket sickness and accident policy shall be payable to the person insured or the person's agent, or to the person's designated beneficiary or beneficiaries, or to the person's estate, except that if the person insured is a minor, such benefits may be made payable to the minor's parent, guardian or other person actually supporting the minor.
D. A blanket sickness or accident policy or contract issued to a college, school or other institution of learning or to the head or principal thereof shall not be identified or sold as a student health plan.
History:
Laws 1984, ch. 127, § 461; 2017, ch. 130, § 15.
ANNOTATIONS
Cross references.
— For existing forms and filings,
see
notes following 59A-5-21 NMSA 1978.
The 2017 amendment,
effective July 1, 2017, prohibited certain blanket sickness or accident policies from being sold as student health plans; in Subsection A, in the introductory language, after "groups of not", deleted "less" and added "fewer", after "ten", deleted "(10)", and after "the following paragraphs", deleted "(1) to (5) inclusive"; and added Subsection D.