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1,724 sections in this chapter.
NMSA 1978, § 59A-22A-5 Health benefit plans
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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…
NMSA 1978, § 59A-22A-6 Preferred provider participation requirements
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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, ag…
NMSA 1978, § 59A-22A-7 General requirements
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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.
NMSA 1978, § 59A-22B-1 Short title
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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.
NMSA 1978, § 59A-22B-2 Definitions
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As used in the Prior Authorization Act: A. "adjudicate" means to approve or deny a request for prior authorization; B. "auto-adjudicate" means to use technology and automation to make a near-real- time determination to approve, deny or pend a request for prior authorization; C. "…
NMSA 1978, § 59A-22B-3 Emergency care
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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.
NMSA 1978, § 59A-22B-4 Duties of office; prescribing penalties
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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 medic…
NMSA 1978, § 59A-22B-5 Prior authorization requirements
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A. A health insurer or pharmacy benefits manager that offers prior authorization shall: (1) use the uniform prior authorization forms developed by the office for medical care, for pharmaceutical benefits or related benefits pursuant to Section 59A- 22B-4 NMSA 1978 and for prescri…
NMSA 1978, § 59A-22B-6 Prior authorization rescinding or modifying prohibited
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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 viola…
NMSA 1978, § 59A-22B-7 Prior authorization or referral requirement for in
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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…
NMSA 1978, § 59A-22B-8 Prior authorization for prescription drugs or step
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therapy for certain conditions prohibited. A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, a rare disease or condition, a serious mental illness or a substance use disorder, pu…
NMSA 1978, § 59A-23-1 Scope of article
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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.
NMSA 1978, § 59A-23-10 Employer utilization and loss data availability
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Claims information, including utilization and loss experience under health insurance provided under Chapter 59A, Article 23 NMSA 1978 shall be made available only upon the request of and to employers of employees with such coverage within sixty days of an employer's written reque…
NMSA 1978, § 59A-23-11 Private health insurance cooperatives; incorporation
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A. A person may form a cooperative to purchase employer health benefit plans. A cooperative shall be organized as a nonprofit corporation and has the rights and duties provided by the Nonprofit Corporation Act [Chapter 53, Article 8 NMSA 1978]. B. Two or more large employers or s…
NMSA 1978, § 59A-23-12 Prescription drug prior authorization protocols
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A. After January 1, 2014, an 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…
NMSA 1978, § 59A-23-12.1 Prescription drug coverage; step therapy protocols;
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clinical review criteria; exceptions. A. Each group or blanket health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in this state that provides a prescription drug benefit for which any step therapy protocols are required …
NMSA 1978, § 59A-23-12.2 Pharmacist prescriptive authority services;
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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 insur…
NMSA 1978, § 59A-23-12.3 Calculating an insured's cost-sharing obligation for
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prescription drug coverage. A. When calculating an insured's cost-sharing obligation for covered prescription drugs, pursuant to a group health plan other than a small group health plan or a blanket health insurance policy or contract that is delivered, issued for delivery or ren…
NMSA 1978, § 59A-23-13 Pharmacy benefits; prescription synchronization
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A. A group or blanket 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 or device benefit shall allow an insured to fill or refill a prescription for l…
NMSA 1978, § 59A-23-14 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. An insurer shall not require a pr…
NMSA 1978, § 59A-23-15 Physical rehabilitation services; limits on cost sharing
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A. A group or blanket 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 …
NMSA 1978, § 59A-23-16 Behavioral health services; elimination of cost sharing
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A. A group or blanket 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 …
NMSA 1978, § 59A-23-17 Anatomical gift nondiscrimination
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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…
NMSA 1978, § 59A-23-18 Diagnostic and supplemental breast examinations
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A. A blanket 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 provides coverage for diagnostic and supplemental breast examinations shall not impose cost sharing for diagnost…
NMSA 1978, § 59A-23-19 Chiropractic physician services; limits on cost sharing
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and coinsurance. A. A group or blanket 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 coi…
NMSA 1978, § 59A-23-2 Blanket health insurance
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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, c…
NMSA 1978, § 59A-23-20 Employee leasing contractor group health plan
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requirements. A. A group health plan sponsored by an employee leasing contractor shall be treated as a multiple employer welfare arrangement for purposes of the Insurance Code. B. A group health plan sponsored by an employee leasing contractor shall be a fully insured plan. C. Fo…
NMSA 1978, § 59A-23-21 Sexually transmitted infection care; cost sharing
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eliminated. A. A blanket 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…
NMSA 1978, § 59A-23-22 Definitions
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As used in Sections 14 through 22 [59A-23-22 to 59A-23-30 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-23-23 Benefits required
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A group health plan, other than a small group health plan or a blanket health insurance policy or 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 recogni…
NMSA 1978, § 59A-23-24 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 an insurer complies with federal and state laws, rules and regulations applicable to coverage for mental health or substance use disorder services. B. An insurer shall not impose quantitative treatm…
NMSA 1978, § 59A-23-25 Provider network adequacy
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A. An insurer 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 prov…
NMSA 1978, § 59A-23-26 Utilization review of mental health or substance use
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disorder services. A. An insurer shall, at least monthly, review and update the insurer'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 …
NMSA 1978, § 59A-23-27 Prohibited exclusions of coverage for mental health or
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substance use disorder services. An insurer 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-23-28 Level of care determinations for the provision of mental
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health or substance use disorder services. A. An insurer shall provide coverage for all in-network mental health or substance use disorder services, consistent with generally recognized standards of care, including placing an insured into a medically necessary level of care. B. C…
NMSA 1978, § 59A-23-29 Coordination of care
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At the request of an insured, an insurer may facilitate communication between mental health or substance use disorder services providers and the insured's designated primary care provider to ensure coordination of care to prevent any conflicts of care that could be harmful to the…
NMSA 1978, § 59A-23-3 Group health insurance
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A. Group health insurance is that form of health insurance covering groups of persons, with or without their dependents, and issued upon the following basis: (1) under a policy issued to an employer, who shall be deemed the policyholder, insuring at least one employee of such emp…
NMSA 1978, § 59A-23-3.1 Group insurance reports required
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A. At least quarterly, upon request by the employer, each insurer who has delivered or issued for delivery a policy of group insurance covering twenty-six or more employees, all or a portion of the premiums for which is paid by the employer of the insureds, shall submit to the em…
NMSA 1978, § 59A-23-30 Confidentiality provisions
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An insurer shall protect the confidentiality of an insured receiving mental health or substance use disorder services. History: Laws 2023, ch. 114, § 22.
NMSA 1978, § 59A-23-31 Exceptions
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The provisions of Sections 14 through 22 [59A-23-22 to 59A-23-30 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, § 23.
NMSA 1978, § 59A-23-32 Medical necessity and nondiscrimination standards for
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coverage of prosthetic devices, custom orthotic devices or complex rehabilitation technology devices. A. A group health plan that is delivered, issued for delivery or renewed in this state that covers essential health benefits or covers prosthetic devices, custom orthotic devices…
NMSA 1978, § 59A-23-4 Other provisions applicable
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A. A blanket or group health insurance policy or contract shall not contain a provision relative to notice or proof of loss or the time for paying benefits or the time within which suit may be brought upon the policy that in the superintendent's opinion is less favorable to the i…
NMSA 1978, § 59A-23-5 Extended disability benefit
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Any group health insurance policy may provide for payment not exceeding one thousand dollars ($1,000) as an extended disability benefit upon the insured's death from any cause, which benefit shall not be construed as life insurance. History: Laws 1984, ch. 127, § 464.
NMSA 1978, § 59A-23-6 Alcohol dependency coverage
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A. Each insurer that delivers or issues for delivery in this state a group health insurance policy shall offer and make available benefits for the necessary care and treatment of alcohol dependency. Such benefits shall: (1) be subject to annual deductibles and coinsurance consist…
NMSA 1978, § 59A-23-6.1 Coverage of alpha-fetoprotein IV screening test
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A blanket or group health 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 between sixteen and twenty weeks of…
NMSA 1978, § 59A-23-6.2 Prior authorization for gynecological or obstetrical
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ultrasounds prohibited. A. A blanket or group health insurance policy or contract that is delivered, issued for delivery or renewed in this state and that provides coverage for gynecological or obstetrical ultrasounds shall not require prior authorization for gynecological or obs…
NMSA 1978, § 59A-23-7 Blanket or group health policy or certificate; provisions
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relating to individuals who are eligible for medical benefits under the medicaid program. A. Each blanket or group health policy or certificate of insurance that is delivered, issued for delivery or renewed in this state shall include provisions that require benefits paid on beha…
NMSA 1978, § 59A-23-7.10 Coverage for orally administered anticancer
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medications; limits on patient costs. A. A blanket or group health insurance policy or 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 anticancer …
NMSA 1978, § 59A-23-7.11 Coverage of prescription eye drop refills
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A. A blanket or group health insurance policy or 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 requested by th…
NMSA 1978, § 59A-23-7.12 Coverage for telemedicine services
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A. A blanket or group health insurance policy or 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 health insurance plan, policy or contract covers the same services w…
