Chapter 59A — Chapter 59A

Coverage of vasectomy and male condoms pursuant to Section 9 [59A-47-45.5 NMSA 1978] of this 2019 act is excluded for high-deductible health care plans with health savings accounts until a covered person's deductible has been met. History: Laws 2019, ch. 263, § 10.

A. A group health care plan, other than a small group health care plan, that is delivered, issued for delivery or renewed in this state shall provide coverage for eligible subscribers to receive a heart artery calcium scan. B. Coverage provided pursuant to this section shall: (1)…

A. Each health care plan delivered or issued for delivery in this state shall provide coverage for individuals with diabetes who use insulin, individuals with diabetes who do not use insulin and with elevated blood glucose levels induced by pregnancy. This coverage shall be a bas…

A. An individual or group health care plan that is delivered, issued for delivery or renewed in this state shall provide coverage for subscribers to receive biomarker testing. B. Coverage provided pursuant to this section shall be for the purposes of diagnosis, treatment, appropr…

History: Laws 2010, ch. 94, § 4; 2013, ch. 74, § 33; 2018, ch. 57, § 26; 2019, ch. 235, § 15; 2019, ch. 235, § 16; repealed by Laws 2021, ch. 108, § 37.

A. After January 1, 2014, a health care plan 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 l…

clinical review criteria; exceptions. A. Each individual or group nonprofit health care plan 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 criteri…

reimbursement parity. A health care plan 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 subscriber at the same rate that the carrier reimbur…

A. An individual or group health care plan that is delivered, issued for delivery or renewed in this state and that provides a prescription drug benefit shall allow a subscriber to fill or refill a prescription for less than a thirty-day supply of the prescription drug, and apply…

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 health care plan shall not requ…

The superintendent shall not authorize any proposed health care plan to solicit preliminary applications from subscribers or to transact business as a health care plan unless he finds after such investigation and hearings as he deems advisable that the proposed health care plan i…

A. An individual or group health care plan 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 coinsura…

A. An individual or group health care plan 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) "be…

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…

A. An individual or group health care plan 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 provisio…

and coinsurance. A. An individual or group health care plan 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 e…

eliminated. A. An individual or group health care plan 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 subscribers. B. Pursuant to th…

As used in Sections 35 through 43 [59A-47-56 to 59A-47-64 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 …

A health care plan, other than a small health care plan, 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. History: Laws 2023, ch. 114…

disorder services. A. The office of superintendent of insurance shall ensure that a health care plan complies with federal and state laws, rules and regulations applicable to coverage for mental health or substance use disorder services. B. A health care plan shall not impose qua…

A. A health care plan 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 servi…

A. A newly-formed health care plan shall not solicit any subscriber or enter into any proposed contract for health care expense payments unless and until it obtains from the superintendent a preliminary permit to do so. The proposed health care plan shall file with the superinten…

disorder services. A. A health care plan shall, at least monthly, review and update the health care plan'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 substa…

substance use disorder services. A health care plan 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; …

health or substance use disorder services. A. A health care plan shall provide coverage for all in-network mental health or substance use disorder services, consistent with generally recognized standards of care, including placing a subscriber into a medically necessary level of …

At the request of a subscriber, a health care plan may facilitate communication between mental health or substance use disorder services providers and the subscriber's designated primary care provider to ensure coordination of care to prevent any conflicts of care that could be h…

A health care plan shall protect the confidentiality of a subscriber receiving mental health or substance use disorder treatment. History: Laws 2023, ch. 114, § 43.

The provisions of Sections 35 through 43 [59A-47-56 to 59A-47-64 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, § 44.

coverage of prosthetic devices, custom orthotic devices or complex rehabilitation technology devices. A. An individual or group health care plan that is delivered, issued for delivery or renewed in this state that covers essential health benefits and covers prosthetic devices, cu…

With its application for a preliminary permit as provided for in Section 879.4 [59A-47- 6 NMSA 1978] of this article the applicant shall file with the superintendent documentation of an escrow arrangement made by applicant and satisfactory to the superintendent adequate to insure…

conditions; exceptions. A. No health care plan shall make health care expense payments unless and until it has obtained from the superintendent a certificate of authority to do business. Violation of this provision shall constitute a misdemeanor punishable upon conviction by a fi…

A. If after such investigation as he deems advisable the superintendent finds that the applicant is in sound financial condition and is otherwise qualified therefor, he shall issue to the applicant a certificate of authority as a health care plan. B. If the superintendent does no…

This article [Chapter 59A, Article 48 NMSA 1978] may be cited as the "Prepaid Dental Plan Law". History: Laws 1984, ch. 127, § 880.

A. Every prepaid dental plan organization annually on or before the first day of March shall file with the superintendent a report covering its activities for the preceding calendar year in form as prescribed by the superintendent, verified by at least two principal officers of t…

ANNOTATIONS Repeals. — Laws 1991, ch. 9, § 45 repealed 59A-48-11 NMSA 1978, as enacted by Laws 1984, ch. 127, § 890, relating to taxes, effective July 1, 1993.

No more than thirty percent of prepaid charges in the first year of operation, twenty- five percent in the second year of operation and twenty percent of prepaid charges in any subsequent year shall be used for the marketing and administrative expenses of a prepaid dental plan or…

Article 16 [Chapter 59A, Article 16 NMSA 1978] of the Insurance Code relating to unfair trade practices and frauds shall apply to prepaid dental plan organizations, except as to the extent the superintendent determines that the nature of prepaid dental plan organizations render p…

Solicitation of memberships in a prepaid dental plan shall be conducted by agents duly appointed by the dental plan organization or solicitors duly appointed by such agents, while licensed as such agents or solicitors under the same provisions and requirements of Articles 11 [Cha…

A. The superintendent may suspend or revoke any certificate of authority of a prepaid dental plan organization if he finds that any of the following conditions exist: (1) the prepaid dental plan organization is operating contrary to its basic organizational documents or in a mann…

A. The prepaid dental plan organization shall prior to use thereof file with the superintendent for his approval all advertising and sales material proposed to be used by it, through agents, solicitors, or otherwise, in advertising solicitation or sale of membership coverage to b…

providers. Solicitation by prepaid dental plan organizations or anyone acting on their behalf to educate members and potential members of the coverage and operation of the organization's plan shall not be construed to be a violation of any provisions of law relating to solicitati…

Any conservation, rehabilitation or liquidation of a prepaid dental plan organization shall be deemed to be that of an insurer and shall be conducted pursuant to Article 41 [Chapter 59A, Article 41 NMSA 1978] of the Insurance Code. History: Laws 1984, ch. 127, § 897.

In addition to those referred to in Chapter 59A, Article 48 NMSA 1978, the following articles and provisions of the Insurance Code [Chapter 59A NMSA 1978] shall also apply, to the extent reasonably applicable and subject to the provisions of that article, as to prepaid dental pla…

As used in this article: A. "member" means an individual who is enrolled in a group prepaid dental plan as a principal subscriber together with such person's dependents who are entitled to dental care services under the plan solely because of their status as dependents of the pri…

No person may establish or operate a prepaid dental plan organization in New Mexico, or sell or offer to sell or solicit offers to purchase, or receive advance or periodic consideration in conjunction with a prepaid dental plan without obtaining and maintaining a certificate of a…

A. An application for a certificate of authority to operate as a prepaid dental plan organization shall be filed with the superintendent in form prescribed by the superintendent, shall be verified by an officer or authorized representative of the applicant and shall set forth or …

A. Issuance of a certificate of authority shall be granted by the superintendent if the superintendent is satisfied that the following conditions are met: (1) the persons responsible for conducting the affairs of the prepaid dental plan organization are competent and trustworthy …

A. A prepaid dental plan organization shall maintain on deposit with the state treasurer through the superintendent a surety bond guaranteeing services under the plan, or cash or securities eligible for investments of capital funds of health insurers under Chapter 59A, Article 9 …

A. A prepaid dental plan organization at all times shall maintain for protection of the members a financial reserve consisting of two percent of prepaid charges collected from members for the plan, until such reserve totals five hundred thousand dollars ($500,000). Such reserve s…

A. Every member in a prepaid dental plan shall be issued a membership coverage form by the prepaid dental plan organization. B. Any contract applied for that provides family coverage shall, as to such coverage of individuals in the family, also provide that the benefits applicabl…