Chapter 59A — Chapter 59A
1,829 sections in this chapter.
NMSA 1978, § 59A-46-41.3 Diagnostic and supplemental breast examinations
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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 exami…
NMSA 1978, § 59A-46-42 Coverage for cytologic and human papillomavirus
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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 heal…
NMSA 1978, § 59A-46-42.1 Coverage for the human papillomavirus vaccine
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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 preventio…
NMSA 1978, § 59A-46-43 Coverage for individuals with diabetes
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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. Th…
NMSA 1978, § 59A-46-43.2 Coverage for medical diets for genetic inborn errors of
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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…
NMSA 1978, § 59A-46-44 Coverage for contraception
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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 con…
NMSA 1978, § 59A-46-45 Coverage for smoking cessation treatment
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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 deducti…
NMSA 1978, § 59A-46-46 Coverage of alpha-fetoprotein IV screening test
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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 betwee…
NMSA 1978, § 59A-46-47 Coverage of part-time employees
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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 …
NMSA 1978, § 59A-46-48 Coverage of colorectal cancer screening
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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 c…
NMSA 1978, § 59A-46-49 General anesthesia and hospitalization for dental
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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 fo…
NMSA 1978, § 59A-46-5 Powers of health maintenance organizations
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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 reason…
NMSA 1978, § 59A-46-50 Coverage for autism spectrum disorder diagnosis and
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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) trea…
NMSA 1978, § 59A-46-50.1 Coverage for orally administered anticancer
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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 an…
NMSA 1978, § 59A-46-50.2 Coverage of prescription eye drop refills
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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 reques…
NMSA 1978, § 59A-46-50.3 Coverage for telemedicine services
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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…
NMSA 1978, § 59A-46-50.4 Prescription drugs; prohibited formulary changes;
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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…
NMSA 1978, § 59A-46-50.5 Heart artery calcium scan coverage
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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…
NMSA 1978, § 59A-46-51 Repealed
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History: Laws 2010, ch. 94, § 3; 2013, ch. 74, § 32; 2018, ch. 57, § 24; 2019, ch. 235, § 11; 2019, ch. 235, § 12; repealed by Laws 2021, ch. 108, § 37.
NMSA 1978, § 59A-46-52 Prescription drug prior authorization protocols
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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…
NMSA 1978, § 59A-46-52.1 Prescription drug coverage; step therapy protocols;
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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…
NMSA 1978, § 59A-46-52.2 Pharmacist prescriptive authority services;
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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…
NMSA 1978, § 59A-46-52.3 Calculating an enrollee's cost-sharing obligation for
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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…
NMSA 1978, § 59A-46-53 Pharmacy benefits; prescription synchronization
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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…
NMSA 1978, § 59A-46-54 Provider credentialing; requirements; deadline
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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…
NMSA 1978, § 59A-46-55 Coverage exclusion. (Contingent repeal. See note
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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…
NMSA 1978, § 59A-46-56 Physical rehabilitation services; limits on cost sharing
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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…
NMSA 1978, § 59A-46-57 Behavioral health services; elimination of cost sharing
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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 …
NMSA 1978, § 59A-46-58 Anatomical gift nondiscrimination
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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…
NMSA 1978, § 59A-46-59 Chiropractic physician services; limits on cost sharing
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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…
NMSA 1978, § 59A-46-6 Fiduciary responsibilities; fidelity bond
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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…
NMSA 1978, § 59A-46-60 Sexually transmitted infection care; cost sharing
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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…
NMSA 1978, § 59A-46-61 Definitions
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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…
NMSA 1978, § 59A-46-62 Benefits required
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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…
NMSA 1978, § 59A-46-63 Parity for coverage of mental health or substance use
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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…
NMSA 1978, § 59A-46-64 Provider network adequacy
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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…
NMSA 1978, § 59A-46-65 Utilization review of mental health or substance use
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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…
NMSA 1978, § 59A-46-66 Prohibited exclusions of coverage for mental health or
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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 …
NMSA 1978, § 59A-46-67 Level of care determinations for the provision of mental
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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…
NMSA 1978, § 59A-46-68 Coordination of care
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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…
NMSA 1978, § 59A-46-69 Confidentiality provisions
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A carrier shall protect the confidentiality of an enrollee receiving mental health or substance use disorder treatment. History: Laws 2023, ch. 114, § 33.
NMSA 1978, § 59A-46-7 Quality assurance program
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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…
NMSA 1978, § 59A-46-70 Exceptions
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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.
NMSA 1978, § 59A-46-71 Biomarker testing coverage
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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…
NMSA 1978, § 59A-46-72 Medical necessity and nondiscrimination standards for
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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…
NMSA 1978, § 59A-46-8 Requirements for group contract, individual contract and
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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 …
NMSA 1978, § 59A-46-9 Annual report
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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…
NMSA 1978, § 59A-47-1 Short title
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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.
NMSA 1978, § 59A-47-10 Trust deposit
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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…
NMSA 1978, § 59A-47-11 Expiration, continuance of certificate of authority
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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…