Chapter 59A — Chapter 59A
1,829 sections in this chapter.
NMSA 1978, § 59A-22-43 Required coverage of patient costs incurred in cancer
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clinical trials. A. A health plan shall provide coverage for routine patient care costs incurred as a result of the patient's participation in a cancer clinical trial if: (1) the clinical trial is undertaken for the purposes of the prevention of or the prevention of reoccurrence …
NMSA 1978, § 59A-22-44 Coverage for smoking cessation treatment
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A. An individual or group health insurance policy, health care plan or certificate of health insurance 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…
NMSA 1978, § 59A-22-45 Coverage of alpha-fetoprotein IV screening test
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An individual or group health insurance 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 t…
NMSA 1978, § 59A-22-46 Coverage of part-time employees
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An insurer that provides group health insurance pursuant to Chapter 59A, Article 22 NMSA 1978 shall make available, upon an employer's request prior to issuance, delivery or renewal, coverage for regular part-time employees who work or are expected to work an average of at least …
NMSA 1978, § 59A-22-47 Coverage of colorectal cancer screening
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A. An individual or group health insurance policy, health care plan and certificate of health insurance 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 condit…
NMSA 1978, § 59A-22-48 General anesthesia and hospitalization for dental
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surgery. A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state shall provide coverage for hospitalization and general anesthesia provided in a hospital or ambulatory s…
NMSA 1978, § 59A-22-49 Coverage for autism spectrum disorder diagnosis and
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treatment. A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state shall provide coverage to an insured for: (1) well-baby and well-child screening for diagnosing the pr…
NMSA 1978, § 59A-22-49.1 Coverage for orally administered anticancer
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medications; limits on patient costs. A. An individual or group 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 coverage for cancer treatment shall provide coverage for …
NMSA 1978, § 59A-22-49.2 Coverage of prescription eye drop refills
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A. An individual or group 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 coverage for prescription eye drops shall not deny coverage for a renewal of prescription eye d…
NMSA 1978, § 59A-22-49.3 Coverage for telemedicine services
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A. An individual or group health insurance policy, health care plan or certificate of health insurance 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, …
NMSA 1978, § 59A-22-49.4 Prescription drugs; prohibited formulary changes;
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notice requirements. A. As of January 1, 2014, an individual or group 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 prescription drug benefits categorized or tiered fo…
NMSA 1978, § 59A-22-5 Time limit on certain defenses
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A. There shall be a provision for comprehensive major medical policies as follows: As of the date of issue of this policy, no misstatements, except willful or fraudulent misstatements, made by the applicant in the application for this policy shall be used to void the policy or to…
NMSA 1978, § 59A-22-50 Health insurers; direct services
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A. A health insurer shall reimburse direct services as follows: (1) for small groups, at no less than eighty percent of aggregate premiums for all such products; and (2) for large groups, at no less than eighty-five percent of aggregate premiums for all such products. B. Reimburs…
NMSA 1978, § 59A-22-51 Dental insurance plan; dental fees not covered;
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severability. A. As used in this section: (1) "covered services" means dental care services for which a reimbursement is available under an enrollee's plan contract or for which a reimbursement would be available but for the application of contractual limitations such as deductib…
NMSA 1978, § 59A-22-52 Prescription drug prior authorization protocols
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A. After January 1, 2014, a health 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 lat…
NMSA 1978, § 59A-22-53 Pharmacy benefits; prescription synchronization
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A. An individual 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 benefit shall allow an insured to fill or refill a prescription for less than a thir…
NMSA 1978, § 59A-22-53.1 Prescription drug coverage; step therapy protocols;
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clinical review criteria; exceptions. A. Each individual 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 shall …
NMSA 1978, § 59A-22-53.2 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-22-53.3 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 an individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed i…
NMSA 1978, § 59A-22-54 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. An insurer shall not require a pr…
NMSA 1978, § 59A-22-55 Coverage exclusion. (Contingent repeal. See note.)
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Coverage of vasectomy and male condoms pursuant to Section 3 [59A-22-42 NMSA 1978] of this 2019 act is excluded for high-deductible individual and group health insurance policies, health care plans or certificates of insurance with health savings accounts delivered or issued for …
NMSA 1978, § 59A-22-56 Physical rehabilitation services; limits on cost sharing
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A. An individual or group 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 c…
NMSA 1978, § 59A-22-57 Behavioral health services; elimination of cost sharing
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A. An individual 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 of behavioral health services shall not impose cost sharing on those behavioral health servi…
NMSA 1978, § 59A-22-58 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-22-59 Chiropractic physician services; limits on cost sharing
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and coinsurance. A. An individual 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 of the services of a chiropractic physician shall not impose a copayment or…
NMSA 1978, § 59A-22-6 Grace period
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There shall be a provision as follows: A grace period of . . . . . . . . (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the f…
NMSA 1978, § 59A-22-60 Sexually transmitted infection care; cost sharing
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eliminated. A. An individual 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 im…
NMSA 1978, § 59A-22-61 Biomarker testing coverage
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A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state shall provide coverage for insureds to receive biomarker testing for the purposes of diagnosis, treatment, approp…
NMSA 1978, § 59A-22-62 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 health plan that is delivered, issued for delivery or renewed in this state that offers coverage for prosthetic devices, custom orthotic devices or complex rehab…
NMSA 1978, § 59A-22-7 Reinstatement
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There shall be a provision as follows: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurance company to accept such premium, without requiring in conne…
NMSA 1978, § 59A-22-8 Notice of claim
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There shall be a provision as follows: Written notice of claim must be given to the insurance company within twenty days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the in…
NMSA 1978, § 59A-22-9 Claim forms
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There shall be a provision as follows: The insurance company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice t…
NMSA 1978, § 59A-22A-1 Short title
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Chapter 59A, Article 22A NMSA 1978 shall be known and may be cited as the "Preferred Provider Arrangements Law". History: 1978 Comp., § 59A-22A-1, enacted by Laws 1993, ch. 320, § 59.
NMSA 1978, § 59A-22A-2 Purpose
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The purpose of the Preferred Provider Arrangements Law is to encourage health care cost containment while preserving quality of care by allowing health care insurers to enter into preferred provider arrangements in accordance with minimum standards for preferred provider arrangem…
NMSA 1978, § 59A-22A-3 Definitions
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As used in the Preferred Provider Arrangements Law: A. "covered person" means any person on whose behalf the health care insurer is obligated to pay for or to provide health benefit services; B. "covered services" means health care services which the health care insurer is obliga…
NMSA 1978, § 59A-22A-4 Preferred provider arrangements
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Notwithstanding any provisions of law to contrary, any health care insurer may enter into preferred provider arrangements. A. Such arrangements shall: (1) establish the amount and manner of payment to the preferred provider. Such amount and manner of payment may include capitatio…
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. ARTICLE 22B Prior…
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…