New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.9 - SUPPLEMENTAL HEALTH CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				A health care insurer, through its MHCP, may provide to its covered persons
				supplemental health care services that are not basic health care services. For
				HMOs, basic health care services are defined and described at 13.10.21.8 NMAC.
				These supplemental health care services may be limited as to time and
				cost.
B.
Additional
				fees:
A health care insurer may determine the level and scope of any
				supplemental health care service provided to its covered persons in a MHCP,
				whether or not the service is listed in this section, and may charge additional
				fees for those services.
C. The
				following are not required as basic health care services, but may be provided
				as supplemental health care services:
(1)
				consultation with and referral to physicians and other health care
				professionals such as dentists, nurses, podiatrists, optometrists, chiropractic
				physicians, physician assistants, clinical psychologists, social workers,
				pharmacists, nutritionists, occupational therapists, physical therapists,
				certified nurse midwives and other professionals engaged in the delivery of
				health services who are licensed to practice, are certified, and are practicing
				under authority of the MHCP, a medical group, an independent practice
				association or other authority authorized by applicable New Mexico law when
				treatment exceeds that included in basic health care services;
(2) corrective appliances, prosthetics, and
				artificial aids, including hearing aids, except as required in Section
				13-7-10
				NMSA 1978;
(3) mental health
				services, including, but not limited to, outpatient evaluative, crisis
				intervention and short term therapeutic mental health services and inpatient
				psychiatric care, except as required in Section 59A-23E 18 NMSA 1978;
(4) cosmetic surgery;
(5) pharmaceuticals and other medicines
				prescribed on an outpatient basis by licensed physicians nurse practitioners,
				physician assistants or certified nurse-midwives to treat or prevent
				illness;
(6) ambulance services,
				other than for emergencies or otherwise deemed medically necessary;
(7) care for military service-connected
				disabilities for which a covered person is legally entitled to services and for
				which facilities are reasonably available to the covered person;
(8) care for conditions that state or local
				law requires be treated in a public facility;
(9) dental services not required as a basic
				health care service;
(10) vision
				care;
(11) personal or comfort
				items;
(12) long-term physical
				therapy and rehabilitation;
(13)
				durable medical equipment for home use, such as wheel chairs, surgical beds,
				respirators, and dialysis machines;
(14) diagnosis, medical treatment and
				referral services for the abuse of or addiction to alcohol or drugs, including
				inpatient substance abuse care in a facility licensed to provide residential
				alcohol and drug abuse services, except as required by Section 59A-23-6 NMSA
				1978;
(15) home health care
				services which, if offered, at a minimum shall comply with Section 59A-22-36
				and Section 59A-46-40 NMSA 1978;
(16) skilled or intermediate nursing
				care;
(17) custodial or domiciliary
				care;
(18) hearing care, except as
				required for children by Section 59A-22-34.5 NMSA 1978;
(19) experimental or investigational medical,
				surgical, other health care procedures or treatments, including drugs, unless
				approved as a basic health care service treatment or procedure by the health
				care insurer. As used in this section, "experimental" or "investigational" as
				related to drugs, devices, medical treatments or procedures means:
(a) the drug or device cannot be lawfully
				marketed without approval of the FDA and approval for marketing has not been
				given at the time the drug or device is furnished;
(b) reliable evidence shows that the drug,
				device or medical treatment or procedure is the subject of on-going phase I,
				II, or III clinical trials or under study to determine its maximum tolerated
				dose, its toxicity, its safety, its efficacy, or its efficacy as compared with
				the standard means of treatment or diagnosis;
(c) reliable evidence shows that the
				consensus among experts regarding the drug, device, or medical treatment or
				procedure is that further studies or clinical trials are necessary to determine
				its maximum tolerated dose, toxicity, safety, or efficacy as compared with the
				standard means of treatment or diagnosis; or
(d) except as required by 13.10.13.10 NMAC,
				the drug or device is used for a purpose that is not approved by the
				FDA;
(e) for the purposes of this
				section, "reliable evidence" shall mean only published reports and articles in
				the authoritative medical and scientific literature listed in Subsection A of
				13.10.13.10 NMAC; the written protocol or protocols used by the treating
				facility or the protocol(s) of another facility studying substantially the same
				drug, device or medical treatment or procedure; or the written informed consent
				used by the treating facility or by another facility studying substantially the
				same drug, device or medical treatment or procedure;
(f) as used in this section, "experimental"
				or "investigational" does not mean cancer chemotherapy or other types of
				therapy that are the subjects of on-going phase IV clinical trials.