Chapter 59A, Chapter 59A

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 p…

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 d…

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. Coverag…

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 ben…

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 cr…

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…

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 cre…

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 prescr…

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 pro…

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 un…

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 wh…

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 …

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…

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 serv…

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 he…

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 enroll…

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 h…

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 s…

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 treatmen…

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 provi…

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 s…

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 …

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. C…

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 th…

A carrier shall protect the confidentiality of an enrollee receiving mental health or substance use disorder treatment. History: Laws 2023, ch. 114, § 33.

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 p…

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]. History: Laws 2023, ch. 114, § 34.

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 o…

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 cover…

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 …

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…

Chapter 59A, Article 47 NMSA 1978 may be cited as the "Nonprofit Health Care Plan Law". History: Laws 1984, ch. 127, § 878; 2003, ch. 391, § 6.

A. Every health care plan shall make and thereafter maintain a deposit in trust with the state treasurer through the superintendent for the benefit and protection of all of its subscribers, as a condition to being authorized to transact business. The deposit shall consist of Unit…

The certificate of authority of a health care plan issued under this article shall be subject to continuation or expiration upon the same applicable procedures and time periods as provided in Article 5 [Chapter 59A, Article 5 NMSA 1978] (authorization of insurers and general requ…

of authority. The superintendent may suspend, revoke or refuse to continue the certificate of authority of any health care plan if the health care plan no longer fulfills the qualifications therefor as stated in this article or on any applicable ground, procedure and conditions o…

Prior to issuance of its initial certificate of authority, the health care plan shall appoint the superintendent and his successors as its true and lawful attorney upon whom may be served all lawful process in any action or legal proceedings against it by a resident of New Mexico…

As prerequisite to continuance of its certificate of authority, each health care plan shall on or before March 1 each year file with the superintendent and with the national association of insurance commissioners an annual statement in accordance with the requirements of Section …

In determining the financial condition of a health care plan there shall be allowed as assets only such assets allowed as to life or health insurers under Sections 118 [59A-8- 1 NMSA 1978] ("assets" defined) and 119 [59A-8-2 NMSA 1978] (assets not allowed) of the Insurance Code. …

A health care plan shall establish and maintain reserves in amount clearly adequate, as determined by the superintendent, to cover all liabilities for losses incurred and unpaid. History: Laws 1984, ch. 127, § 879.14.

A health care plan, or organizaion [organization] proposing or purporting to be a health care plan, shall be subject to investigation and examination by the superintendent upon the same bases, in the same manner and subject to the same provisions as to conduct of the examination,…

A health care plan shall invest its funds only in such securities and assets as are eligible for investment of the funds of health insurers under Article 9 [Chapter 59A, Article 9 NMSA 1978] (investments) of the Insurance Code, and subject to the provisions of that article as to …

expenses. No health care plan shall during any one calendar year incur expense for acquisition of its business more than ten percent of its premium income earned during that year; nor incur during any such year for expense of administration more than twenty percent of such earned…

A. The purpose of this article is to provide for the reasonable regulation of membership corporations organized for the purpose of making health care expense payments on a service benefit basis or on an indemnity benefit basis, or both, for persons who become subscribers under co…

A. No director or officer of any health care plan, or employee of such plan having authority for investment or expenditure of funds, shall accept except for the health care plan or be beneficiary of any fee, brokerage, gift or other emolument in addition to his fixed salary or co…

Two (2) or more health care plans may enter into and carry out cooperative agreements under which subscribers may subscribe jointly to and receive the benefits of all such plans; and any health care plan may enter into and carry out reinsurance agreements. History: Laws 1984, ch.…

A. A health care plan may enter into agreements with another health care plan or mutual company similarly engaged in this state or another state or country for transfer of subscribers from one such plan to the other, subject to prior approval of any such agreement by the superint…

Every health care expense payments contract made by a health care plan under this article shall provide coverage for the subscribers thereunder for a period of not less than one month; and no such contract shall be made which provides for an effective date which is more than six …

Every health care expense payments contract issued under this article shall be in writing and comply with requirements and contain provisions in substance as follows: A. a provision that the policy, the application of the policyholder (if it or a copy thereof is attached to the p…

No health care plan shall make or issue any health care expense payments contract or certificate therefor unless it has first filed with the superintendent a copy of the form of the proposed contract or certificate and a copy of all applications, riders and endorsements to be use…

A. No health care plan shall enter into any contract with a subscriber unless it has first filed with the superintendent a full schedule of premium rates to be paid by the subscribers. The superintendent shall notify the health care plan of his approval or disapproval of such rat…