Chapter 59A — Chapter 59A
1,829 sections in this chapter.
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-23-7.1 Reserved
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…
NMSA 1978, § 59A-23-7.13 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-23-7.14 Coverage for contraception
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A. Each individual and group 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 shall provide, at a minimum, the following coverage: (1) at least one product or for…
NMSA 1978, § 59A-23-7.15 Coverage exclusion. (Contingent repeal. See note.)
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Coverage of vasectomy and male condoms pursuant to Section 5 [59A-23-7.14 NMSA 1978] of this 2019 act is excluded for high-deductible individual or group health insurance policies, health care plans or certificates of insurance with health savings accounts delivered or issued for…
NMSA 1978, § 59A-23-7.16 Heart artery calcium scan coverage
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A. 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 eligible insureds to receive a heart artery calcium scan. B. Coverage provided …
NMSA 1978, § 59A-23-7.17 Coverage for individuals with diabetes
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A. Each group health insurance contract and blanket health insurance contract 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 leve…
NMSA 1978, § 59A-23-7.18 Biomarker testing coverage
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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 shall provide coverage for insureds to receive biomarker testing. B. Coverage provided pursuant to this section shall…
NMSA 1978, § 59A-23-7.2 Coverage of children
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A. An insurer shall not deny enrollment of a child under the health plan of the child's parent on the grounds that the child: (1) was born out of wedlock; (2) is not claimed as a dependent on the parent's federal tax return; or (3) does not reside with the parent or in the insure…
NMSA 1978, § 59A-23-7.3 Maximum age of dependent
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Each blanket or group health policy or certificate of insurance delivered, issued for delivery or renewed in New Mexico on or after July 1, 2003 that provides coverage for an insured's dependent shall not terminate coverage of an unmarried dependent by reason of the dependent's a…
NMSA 1978, § 59A-23-7.4 Coverage of circumcision for newborn males
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A blanket 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 circumcision for newborn males. History: Laws 2004, ch. 122, § 6.
NMSA 1978, § 59A-23-7.5 Coverage of part-time employees
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An insurer that provides group health insurance pursuant to Chapter 59A, Article 23 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-23-7.6 Coverage of colorectal cancer screening
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A. A blanket or group health policy, health care plan or 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 conditions and other …
NMSA 1978, § 59A-23-7.7 General anesthesia and hospitalization for dental
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surgery. 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 shall provide coverage for hospitalization and general anesthesia provided in a hospital or ambulatory surgi…
NMSA 1978, § 59A-23-7.8 Hearing aid coverage for children required
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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 shall provide coverage for a hearing aid and any related service for the full cost of one hearing aid per hearing-imp…