HB 233/a
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AN ACT
RELATING TO INSURANCE; AMENDING SECTIONS OF THE NEW MEXICO
INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND
THE NONPROFIT HEALTH CARE PLAN LAW TO REQUIRE COVERAGE FOR
CERTAIN DURABLE MEDICAL EQUIPMENT FOR THE TREATMENT OF ACTIVE
DIABETIC FOOT ULCERS.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. Section 59A-22-41 NMSA 1978 (being Laws
1997, Chapter 7, Section 1 and Laws 1997, Chapter 255,
Section 1, as amended) is amended to read:
"59A-22-41. COVERAGE FOR INDIVIDUALS WITH DIABETES.--
A. Each individual and group health insurance
policy, health care plan, certificate of health insurance and
managed health care plan 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.
This coverage shall be a basic health care benefit and shall
entitle each individual to the medically accepted standard of
medical care for diabetes and benefits for diabetes treatment
as well as diabetes supplies, and this coverage shall not be
reduced or eliminated.
B. Except as otherwise provided in this
subsection, coverage for individuals with diabetes may be HB 233/a
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subject to deductibles and coinsurance consistent with those
imposed on other benefits under the same policy, plan or
certificate, as long as the annual deductibles or coinsurance
for benefits are no greater than the annual deductibles or
coinsurance established for similar benefits within a given
policy. The amount an individual with diabetes is required
to pay for a preferred formulary prescription insulin drug or
a medically necessary alternative is an amount not to exceed
a total of twenty-five dollars ($25.00) per thirty-day
supply.
C. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health policies described in that subsection
shall be entitled to the following equipment, supplies and
appliances to treat diabetes:
(1) blood glucose monitors, including those
for individuals with disabilities, including the legally
blind;
(2) test strips for blood glucose monitors;
(3) visual reading urine and ketone strips;
(4) lancets and lancet devices;
(5) insulin;
(6) injection aids, including those
adaptable to meet the needs of individuals with disabilities, HB 233/a
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including the legally blind;
(7) syringes;
(8) prescriptive oral agents for controlling
blood sugar levels;
(9) medically necessary podiatric appliances
for prevention of feet complications associated with
diabetes, including therapeutic molded or depth-inlay shoes,
functional orthotics, custom molded inserts, replacement
inserts, preventive devices and shoe modifications for
prevention and treatment; and
(10) glucagon emergency kits.
D. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health policies described in that subsection
shall be entitled to the following basic health care
benefits:
(1) diabetes self-management training that
shall be provided by a certified, registered or licensed
health care professional with recent education in diabetes
management, which shall be limited to:
(a) medically necessary visits upon the
diagnosis of diabetes;
(b) visits following a diagnosis from a
health care practitioner that represents a significant change HB 233/a
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in the patient's symptoms or condition that warrants changes
in the patient's self-management; and
(c) visits when re-education or
refresher training is prescribed by a health care
practitioner with prescribing authority;
(2) medical nutrition therapy related to
diabetes management; and
(3) medically necessary treatment of active
diabetic foot ulcers, including topical oxygen therapy.
E. When new or improved equipment, appliances,
prescription drugs for the treatment of diabetes, insulin or
supplies for the treatment of diabetes are approved by the
federal food and drug administration, all individual or group
health insurance policies as described in Subsection A of
this section shall:
(1) maintain an adequate formulary to
provide those resources to individuals with diabetes; and
(2) guarantee reimbursement or coverage for
the equipment, appliances, prescription drug, insulin or
supplies described in this subsection within the limits of
the health care plan, policy or certificate.
F. An insurer that requires a covered person to
use a specific network provider or to purchase equipment,
appliances, supplies or insulin or prescription drugs for the
treatment or management of diabetes from a specific durable HB 233/a
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medical equipment supplier or other supplier as a condition
of coverage, payment or reimbursement shall:
(1) maintain an adequate network of durable
medical equipment suppliers and other suppliers to provide
covered persons with medically necessary diabetes resources,
whether covered under the health policy's prescription drug
or medical benefit;
(2) have network contracts in place for the
entire policy or plan period and shall not allow contracts
with network providers, durable medical equipment suppliers
and other suppliers to lapse or terminate without ensuring
the availability of a replacement and continuity of care;
provided that single-case agreements do not satisfy the
requirements of Paragraph (1) of this subsection or this
paragraph;
(3) monitor network providers, durable
medical equipment suppliers and other network suppliers to
ensure that medically necessary equipment, appliances,
supplies and insulin or other prescription drugs are being
delivered to a covered person in a timely manner and when
needed by the covered person;
(4) guarantee reimbursement to a covered
person within thirty days following receipt of a written
demand from the covered person who pays out of pocket for
necessary equipment, appliances, supplies and insulin or HB 233/a
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other prescription drugs described in this section that are
not delivered timely to the covered person, and the portion
of payment for which the patient is responsible shall not
exceed the amount for the same covered benefit obtained from
a contracted supplier;
(5) pay interest at the rate of eighteen
percent per year on the amount of reimbursement due to a
covered person if not paid within thirty days as required by
Paragraph (4) of this subsection;
(6) beginning on April 1, 2024, submit a
written report each quarter to the superintendent for the
previous quarter on the following metrics:
(a) the number of written demands for
reimbursement of out-of-pocket expenses from covered persons
received by the health care insurer;
(b) the number of out-of-pocket claims
for reimbursement paid and the aggregate amount of claims
reimbursed by the health care insurer within the time
required by Paragraph (4) of this subsection;
(c) the number of out-of-pocket claims
for reimbursement paid more than thirty days following
receipt of a written demand and the aggregate amount of these
payments, excluding interest; and
(d) the aggregate amount of interest
paid by the health care insurer pursuant to Paragraph (5) of HB 233/a
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this subsection; and
(7) beginning on April 1, 2024, submit a
written report each quarter for the previous quarter to the
superintendent with the following information for each
durable medical equipment supplier or other supplier that was
under contract with the health care insurer or its agent
during the previous quarter:
(a) the name, address and telephone
number of each supplier and, if applicable, the corresponding
date upon which the respective supplier's contract expired,
lapsed or was terminated during the previous quarter;
(b) the percentage of total deliveries,
by description of item, that did not meet the delivery
requirements specified in Paragraph (3) of this subsection;
and
(c) the number of complaints received
by the health care insurer or its agent during the previous
quarter related to late deliveries, incomplete orders or
incorrect orders, respectively.
G. The superintendent shall annually audit all
health insurers offering policies, plans or certificates as
described in Subsection A of this section for compliance with
the requirements of this section. If the superintendent
determines that a health care insurer has not complied with
the requirements of this section, the superintendent shall HB 233/a
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impose corrective action or use any other enforcement
mechanism available to the superintendent to obtain the
health care insurer's compliance with this section.
H. Absent a change in diagnosis or in a covered
person's management or treatment of diabetes or its
complications, a health care insurer shall not require more
than one prior authorization per policy period for any single
drug or category of item enumerated in this section if
prescribed as medically necessary by the covered person's
health care practitioner. Changes in the prescribed dose of
a drug; quantities of supplies needed to administer a
prescribed drug; quantities of blood glucose self-testing
equipment and supplies; or quantities of supplies needed to
use or operate devices for which a covered person has
received prior authorization during the policy year shall not
be subject to additional prior authorization requirements in
the same policy year if prescribed as medically necessary by
the covered person's health care practitioner. Nothing in
this subsection shall be construed to require payment for
diabetes resources that are not covered benefits.
I. The provisions of this section do not apply to
short-term travel, accident-only or limited or specified
disease policies.
J. For purposes of this section:
(1) "basic health care benefits": HB 233/a
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(a) means benefits for medically
necessary services consisting of preventive care, emergency
care, inpatient and outpatient hospital and physician care,
diagnostic laboratory and diagnostic and therapeutic
radiological services; and
(b) does not include services for
alcohol or drug abuse, dental or long-term rehabilitation
treatment; and
(2) "managed health care plan" means a
health benefit plan offered by a health care insurer that
provides for the delivery of comprehensive basic health care
services and medically necessary services to individuals
enrolled in the plan through its own employed health care
providers or by contracting with selected or participating
health care providers. A managed health care plan includes
only those plans that provide comprehensive basic health care
services to enrollees on a prepaid, capitated basis,
including the following:
(a) health maintenance organizations;
(b) preferred provider organizations;
(c) individual practice associations;
(d) competitive medical plans;
(e) exclusive provider organizations;
(f) integrated delivery systems;
(g) independent physician-provider HB 233/a
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organizations;
(h) physician hospital-provider
organizations; and
(i) managed care services
organizations."
SECTION 2. Section 59A-23-7.17 NMSA 1978 (being Laws
2023, Chapter 50, Section 3) is amended to read:
"59A-23-7.17. COVERAGE FOR INDIVIDUALS WITH DIABETES.--
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 levels
induced by pregnancy. This coverage shall be a basic health
care benefit and shall entitle each individual to the
medically accepted standard of medical care for diabetes and
benefits for diabetes treatment as well as diabetes supplies,
and this coverage shall not be reduced or eliminated.
B. Except as otherwise provided in this
subsection, coverage for individuals with diabetes may be
subject to deductibles and coinsurance consistent with those
imposed on other benefits under the same policy, as long as
the annual deductibles or coinsurance for benefits are no
greater than the annual deductibles or coinsurance
established for similar benefits within a given policy. The HB 233/a
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amount an individual with diabetes is required to pay for a
preferred formulary prescription insulin drug or a medically
necessary alternative is an amount not to exceed a total of
twenty-five dollars ($25.00) per thirty-day supply.
C. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health policies described in that subsection
shall be entitled to the following equipment, supplies and
appliances to treat diabetes:
(1) blood glucose monitors, including those
for persons with disabilities, including the legally blind;
(2) test strips for blood glucose monitors;
(3) visual reading urine and ketone strips;
(4) lancets and lancet devices;
(5) insulin;
(6) injection aids, including those
adaptable to meet the needs of persons with disabilities,
including the legally blind;
(7) syringes;
(8) prescriptive oral agents for controlling
blood sugar levels;
(9) medically necessary podiatric appliances
for prevention of feet complications associated with
diabetes, including therapeutic molded or depth-inlay shoes, HB 233/a
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functional orthotics, custom molded inserts, replacement
inserts, preventive devices and shoe modifications for
prevention and treatment; and
(10) glucagon emergency kits.
D. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health policies described in that subsection
shall be entitled to the following basic health care
benefits:
(1) diabetes self-management training that
shall be provided by a certified, registered or licensed
health care professional with recent education in diabetes
management, which shall be limited to:
(a) medically necessary visits upon the
diagnosis of diabetes;
(b) visits following a diagnosis from a
health care practitioner that represents a significant change
in the patient's symptoms or condition that warrants changes
in the patient's self-management; and
(c) visits when re-education or
refresher training is prescribed by a health care
practitioner with prescribing authority;
(2) medical nutrition therapy related to
diabetes management; and HB 233/a
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(3) medically necessary treatment of active
diabetic foot ulcers, including topical oxygen therapy.
E. When new or improved equipment, appliances,
prescription drugs for the treatment of diabetes, insulin or
supplies for the treatment of diabetes are approved by the
federal food and drug administration, all individual or group
health insurance policies as described in Subsection A of
this section shall:
(1) maintain an adequate formulary to
provide those resources to individuals with diabetes; and
(2) guarantee reimbursement or coverage for
the equipment, appliances, prescription drugs, insulin or
supplies described in this subsection within the limits of
the health care plan, policy or certificate.
F. An insurer that requires a covered person to
use a specific network provider or to purchase equipment,
appliances, supplies or insulin or prescription drugs for the
treatment or management of diabetes from a specific durable
medical equipment supplier or other supplier as a condition
of coverage, payment or reimbursement shall:
(1) maintain an adequate network of durable
medical equipment suppliers and other suppliers to provide
covered persons with medically necessary diabetes resources
whether covered under the health policy's prescription drug
or medical benefit; HB 233/a
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(2) have network contracts in place for the
entire policy or plan period and shall not allow contracts
with network providers, durable medical equipment suppliers
and other suppliers to lapse or terminate without ensuring
the availability of a replacement and continuity of care;
provided that single-case agreements do not satisfy the
requirements of Paragraph (1) of this subsection or this
paragraph;
(3) monitor network providers, durable
medical equipment suppliers and other network suppliers to
ensure that medically necessary equipment, appliances,
supplies and insulin or other prescription drugs are being
delivered to a covered person in a timely manner and when
needed by the covered person;
(4) guarantee reimbursement to a covered
person within thirty days following receipt of a written
demand from the covered person who pays out of pocket for
necessary equipment, appliances, supplies and insulin or
other prescription drugs described in this section that are
not delivered in a timely manner to the covered person, and
the portion of payment for which the patient is responsible
shall not exceed the amount for the same covered benefit
obtained from a contracted supplier;
(5) pay interest at the rate of eighteen
percent per year on the amount of reimbursement due to a HB 233/a
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covered person if not paid within thirty days as required by
Paragraph (4) of this subsection;
(6) beginning on April 1, 2024, submit a
written report each quarter to the superintendent for the
previous quarter on the following metrics:
(a) the number of written demands for
reimbursement of out-of-pocket expenses from covered persons
received by the health care insurer;
(b) the number of out-of-pocket claims
for reimbursement paid and the aggregate amount of claims
reimbursed by the health care insurer within the time
required by Paragraph (4) of this subsection;
(c) the number of out-of-pocket claims
for reimbursement paid more than thirty days following
receipt of a written demand and the aggregate amount of these
payments, excluding interest; and
(d) the aggregate amount of interest
paid by the health care insurer pursuant to Paragraph (5) of
this subsection; and
(7) beginning on April 1, 2024, submit a
written report each quarter for the previous quarter to the
superintendent with the following information for each
durable medical equipment supplier or other supplier that was
under contract with the health care insurer or its agent
during the previous quarter: HB 233/a
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(a) the name, address and telephone
number of each supplier and, if applicable, the corresponding
date upon which the respective supplier's contract expired,
lapsed or was terminated during the previous quarter;
(b) the percentage of total deliveries,
by description of item, that did not meet the delivery
requirements specified in Paragraph (3) of this subsection;
and
(c) the number of complaints received
by the health care insurer or its agent during the previous
quarter related to late deliveries, incomplete orders or
incorrect orders, respectively.
G. The superintendent shall annually audit all
health insurers offering policies, plans or certificates as
described in Subsection A of this section for compliance with
the requirements of this section. If the superintendent
determines that a health care insurer has not complied with
the requirements of this section, the superintendent shall
impose corrective action or use any other enforcement
mechanism available to the superintendent to obtain the
health care insurer's compliance with this section.
H. Absent a change in diagnosis or in a covered
person's management or treatment of diabetes or its
complications, a health care insurer shall not require more
than one prior authorization per policy period for any single HB 233/a
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drug or category of item enumerated in this section if
prescribed as medically necessary by the covered person's
health care practitioner. Changes in the prescribed dose of
a drug; quantities of supplies needed to administer a
prescribed drug; quantities of blood glucose self-testing
equipment and supplies; or quantities of supplies needed to
use or operate devices for which a covered person has
received prior authorization during the policy year shall not
be subject to additional prior authorization requirements in
the same policy year if prescribed as medically necessary by
the covered person's health care practitioner. Nothing in
this subsection shall be construed to require payment for
diabetes resources that are not covered benefits.
I. The provisions of this section do not apply to
short-term travel, accident-only or limited or specified
disease policies.
J. For purposes of this section, "basic health
care benefits":
(1) means benefits for medically necessary
services consisting of preventive care, emergency care,
inpatient and outpatient hospital and physician care,
diagnostic laboratory and diagnostic and therapeutic
radiological services; and
(2) does not include services for alcohol or
drug abuse, dental or long-term rehabilitation treatment." HB 233/a
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SECTION 3. Section 59A-46-43 NMSA 1978 (being Laws
1997, Chapter 7, Section 3 and Laws 1997, Chapter 255,
Section 3, as amended) is amended to read:
"59A-46-43. COVERAGE FOR INDIVIDUALS WITH DIABETES.--
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.
This coverage shall be a basic health care service and shall
entitle each individual to the medically accepted standard of
medical care for diabetes and benefits for diabetes treatment
as well as diabetes supplies, and this coverage shall not be
reduced or eliminated.
B. Except as provided in this subsection, coverage
for individuals with diabetes may be subject to deductibles
and coinsurance consistent with those imposed on other
benefits under the same contract, as long as the annual
deductibles or coinsurance for benefits are no greater than
the annual deductibles or coinsurance established for similar
benefits within a given contract. The amount an individual
with diabetes is required to pay for a preferred formulary
prescription insulin drug or a medically necessary
alternative is an amount not to exceed a total of twenty-five
dollars ($25.00) per thirty-day supply. HB 233/a
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C. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled under an individual or group health maintenance
organization contract shall be entitled to the following
equipment, supplies and appliances to treat diabetes:
(1) blood glucose monitors, including those
for individuals with disabilities, including the legally
blind;
(2) test strips for blood glucose monitors;
(3) visual reading urine and ketone strips;
(4) lancets and lancet devices;
(5) insulin;
(6) injection aids, including those
adaptable to meet the needs of individuals with disabilities,
including the legally blind;
(7) syringes;
(8) prescriptive oral agents for controlling
blood sugar levels;
(9) medically necessary podiatric appliances
for prevention of feet complications associated with
diabetes, including therapeutic molded or depth-inlay shoes,
functional orthotics, custom molded inserts, replacement
inserts, preventive devices and shoe modifications for
prevention and treatment; and HB 233/a
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(10) glucagon emergency kits.
D. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled under an individual or group health maintenance
contract shall be entitled to the following basic health care
services:
(1) diabetes self-management training that
shall be provided by a certified, registered or licensed
health care professional with recent education in diabetes
management, which shall be limited to:
(a) medically necessary visits upon the
diagnosis of diabetes;
(b) visits following a diagnosis from a
health care practitioner that represents a significant change
in the patient's symptoms or condition that warrants changes
in the patient's self-management; and
(c) visits when re-education or
refresher training is prescribed by a health care
practitioner with prescribing authority; and
(2) medical nutrition therapy related to
diabetes management.
E. When new or improved equipment, appliances,
prescription drugs for the treatment of diabetes, insulin or
supplies for the treatment of diabetes are approved by the HB 233/a
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federal food and drug administration, each individual or
group health maintenance organization contract shall:
(1) maintain an adequate formulary to
provide these resources to individuals with diabetes; and
(2) guarantee reimbursement or coverage for
the equipment, appliances, prescription drug, insulin or
supplies described in this subsection within the limits of
the health care plan, policy or certificate.
F. A health maintenance organization that requires
an enrollee to use a specific network provider or to purchase
equipment, appliances, supplies or insulin or prescription
drugs for the treatment or management of diabetes from a
specific durable medical equipment supplier or other supplier
as a condition of coverage, payment or reimbursement shall:
(1) maintain an adequate network of durable
medical equipment suppliers and other suppliers to provide
covered persons with medically necessary diabetes resources
whether covered under the health maintenance organization
contract's prescription drug or medical benefit;
(2) have network contracts in place for the
entire contract period and shall not allow contracts with
network providers, durable medical equipment suppliers and
other suppliers to lapse or terminate without ensuring the
availability of a replacement and continuity of care;
provided that single-case agreements do not satisfy the HB 233/a
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requirements of Paragraph (1) of this subsection or this
paragraph;
(3) monitor network providers, durable
medical equipment suppliers and other network suppliers to
ensure that medically necessary equipment, appliances,
supplies and insulin or other prescription drugs are being
delivered to an enrollee in a timely manner and when needed
by the enrollee;
(4) guarantee reimbursement to an enrollee
within thirty days following receipt of a written demand from
the enrollee who pays out of pocket for necessary equipment,
appliances, supplies and insulin or other prescription drugs
described in this section that are not delivered timely to
the enrollee, and the portion of payment for which the
patient is responsible shall not exceed the amount for the
same covered benefit obtained from a contracted supplier;
(5) pay interest at the rate of eighteen
percent per year on the amount of reimbursement due to an
enrollee if not paid within thirty days as required by
Paragraph (4) of this subsection;
(6) beginning on April 1, 2024, submit a
written report each quarter to the superintendent for the
previous quarter on the following metrics:
(a) the number of written demands for
reimbursement of out-of-pocket expenses from enrollees HB 233/a
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received by the health maintenance organization;
(b) the number of out-of-pocket claims
for reimbursement paid and the aggregate amount of claims
reimbursed by the health maintenance organization within the
time required by Paragraph (4) of this subsection;
(c) the number of out-of-pocket claims
for reimbursement paid more than thirty days following
receipt of a written demand and the aggregate amount of these
payments, excluding interest; and
(d) the aggregate amount of interest
paid by the health maintenance organization pursuant to
Paragraph (5) of this subsection; and
(7) beginning on April 1, 2024, submit a
written report each quarter for the previous quarter to the
superintendent with the following information for each
durable medical equipment supplier or other supplier that was
under contract with the health maintenance organization or
its agent during the previous quarter:
(a) the name, address and telephone
number of each supplier and, if applicable, the corresponding
date upon which the respective supplier's contract expired,
lapsed or was terminated during the previous quarter;
(b) the percentage of total deliveries,
by description of item, that did not meet the delivery
requirements specified in Paragraph (3) of this subsection; HB 233/a
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and
(c) the number of complaints received
by the health maintenance organization or its agent during
the previous quarter related to late deliveries, incomplete
orders or incorrect orders, respectively.
G. The superintendent shall annually audit all
health maintenance organizations offering contracts as
described in Subsection A of this section for compliance with
the requirements of this section. If the superintendent
determines that a health maintenance organization has not
complied with the requirements of this section, the
superintendent shall impose corrective action or use any
other enforcement mechanism available to the superintendent
to obtain the health maintenance organization's compliance
with this section.
H. Absent a change in diagnosis or in an
enrollee's management or treatment of diabetes or its
complications, a health maintenance organization shall not
require more than one prior authorization per policy period
for any single drug or category of item enumerated in this
section if prescribed as medically necessary by the
enrollee's health care practitioner. Changes in the
prescribed dose of a drug; quantities of supplies needed to
administer a prescribed drug; quantities of blood glucose
self-testing equipment and supplies; or quantities of HB 233/a
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supplies needed to use or operate devices for which an
enrollee has received prior authorization during the policy
year shall not be subject to additional prior authorization
requirements in the same policy year if prescribed as
medically necessary by the enrollee's health care
practitioner. Nothing in this subsection shall be construed
to require payment for diabetes resources that are not a
covered benefit.
I. The provisions of this section do not apply to
short-term travel, accident-only or limited or specified
disease policies.
J. For purposes of this section, "basic health
care benefits":
(1) means benefits for medically necessary
services consisting of preventive care, emergency care,
inpatient and outpatient hospital and physician care,
diagnostic laboratory and diagnostic and therapeutic
radiological services; and
(2) does not include services for alcohol or
drug abuse, dental or long-term rehabilitation treatment."
SECTION 4. Section 59A-47-45.8 NMSA 1978 (being Laws
2023, Chapter 50, Section 5) is amended to read:
"59A-47-45.8. COVERAGE FOR INDIVIDUALS WITH DIABETES.--
A. Each health care plan delivered or issued for
delivery in this state shall provide coverage for individuals HB 233/a
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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 basic health
care benefit and shall entitle each individual to the
medically accepted standard of medical care for diabetes and
benefits for diabetes treatment as well as diabetes supplies,
and this coverage shall not be reduced or eliminated.
B. Except as otherwise provided in this
subsection, coverage for individuals with diabetes may be
subject to deductibles and coinsurance consistent with those
imposed on other benefits under the same plan as long as the
annual deductibles or coinsurance for benefits are no greater
than the annual deductibles or coinsurance established for
similar benefits within a given plan. The amount an
individual with diabetes is required to pay for a preferred
formulary prescription insulin drug or a medically necessary
alternative is an amount not to exceed a total of twenty-five
dollars ($25.00) per thirty-day supply.
C. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health care plans described in that subsection
shall be entitled to the following equipment, supplies and
appliances to treat diabetes:
(1) blood glucose monitors, including those HB 233/a
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for persons with disabilities, including the legally blind;
(2) test strips for blood glucose monitors;
(3) visual reading urine and ketone strips;
(4) lancets and lancet devices;
(5) insulin;
(6) injection aids, including those
adaptable to meet the needs of persons with disabilities,
including the legally blind;
(7) syringes;
(8) prescriptive oral agents for controlling
blood sugar levels;
(9) medically necessary podiatric appliances
for prevention of feet complications associated with
diabetes, including therapeutic molded or depth-inlay shoes,
functional orthotics, custom molded inserts, replacement
inserts, preventive devices and shoe modifications for
prevention and treatment; and
(10) glucagon emergency kits.
D. When prescribed or diagnosed by a health care
practitioner with prescribing authority, all individuals with
diabetes as described in Subsection A of this section
enrolled in health care plans described in that subsection
shall be entitled to the following basic health care
benefits:
(1) diabetes self-management training that HB 233/a
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shall be provided by a certified, registered or licensed
health care professional with recent education in diabetes
management, which shall be limited to:
(a) medically necessary visits upon the
diagnosis of diabetes;
(b) visits following a diagnosis from a
health care practitioner that represents a significant change
in the patient's symptoms or condition that warrants changes
in the patient's self-management; and
(c) visits when re-education or
refresher training is prescribed by a health care
practitioner with prescribing authority;
(2) medical nutrition therapy related to
diabetes management; and
(3) medically necessary treatment of active
diabetic foot ulcers, including topical oxygen therapy.
E. When new or improved equipment, appliances,
prescription drugs for the treatment of diabetes, insulin or
supplies for the treatment of diabetes are approved by the
federal food and drug administration, all health care plans
as described in Subsection A of this section shall:
(1) maintain an adequate formulary to
provide those resources to individuals with diabetes; and
(2) guarantee reimbursement or coverage for
the equipment, appliances, prescription drugs, insulin or HB 233/a
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supplies described in this subsection within the limits of
the health care plan.
F. A health care plan that requires a subscriber
to use a specific network provider or to purchase equipment,
appliances, supplies or insulin or prescription drugs for the
treatment or management of diabetes from a specific durable
medical equipment supplier or other supplier as a condition
of coverage, payment or reimbursement shall:
(1) maintain an adequate network of durable
medical equipment suppliers and other suppliers to provide
subscribers with medically necessary diabetes resources
whether covered under the health care plan's prescription
drug or medical benefit;
(2) have network contracts in place for the
entire plan period and shall not allow contracts with network
providers, durable medical equipment suppliers and other
suppliers to lapse or terminate without ensuring the
availability of a replacement and continuity of care;
provided that single-case agreements do not satisfy the
requirements of Paragraph (1) of this subsection or this
paragraph;
(3) monitor network providers, durable
medical equipment suppliers and other network suppliers to
ensure that medically necessary equipment, appliances,
supplies and insulin or other prescription drugs are being HB 233/a
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delivered to a subscriber in a timely manner and when needed
by the subscriber;
(4) guarantee reimbursement to a subscriber
within thirty days following receipt of a written demand from
the subscriber who pays out of pocket for necessary
equipment, appliances, supplies and insulin or other
prescription drugs described in this section that are not
delivered timely to the subscriber and the portion of payment
for which the patient is responsible shall not exceed the
amount for the same covered benefit obtained from a
contracted supplier;
(5) pay interest at the rate of eighteen
percent per year on the amount of reimbursement due to a
subscriber if not paid within thirty days as required by
Paragraph (4) of this subsection;
(6) beginning on April 1, 2024, submit a
written report each quarter to the superintendent for the
previous quarter on the following metrics:
(a) the number of written demands for
reimbursement of out-of-pocket expenses from subscribers
received by the health care plan;
(b) the number of out-of-pocket claims
for reimbursement paid and the aggregate amount of claims
reimbursed by the health care plan within the time required
by Paragraph (4) of this subsection; HB 233/a
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(c) the number of out-of-pocket claims
for reimbursement paid more than thirty days following
receipt of a written demand and the aggregate amount of these
payments, excluding interest; and
(d) the aggregate amount of interest
paid by the health care plan pursuant to Paragraph (5) of
this subsection; and
(7) beginning on April 1, 2024, submit a
written report each quarter for the previous quarter to the
superintendent with the following information for each
durable medical equipment supplier or other supplier that was
under contract with the health care plan or its agent during
the previous quarter:
(a) the name, address and telephone
number of each supplier and, if applicable, the corresponding
date upon which the respective supplier's contract expired,
lapsed or was terminated during the previous quarter;
(b) the percentage of total deliveries,
by description of item, that did not meet the delivery
requirements specified in Paragraph (3) of this subsection;
and
(c) the number of complaints received
by the health care plan or its agent during the previous
quarter related to late deliveries, incomplete orders or
incorrect orders, respectively. HB 233/a
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G. The superintendent shall annually audit all
health care plans as described in Subsection A of this
section for compliance with the requirements of this section.
If the superintendent determines that a health care plan has
not complied with the requirements of this section, the
superintendent shall impose corrective action or use any
other enforcement mechanism available to the superintendent
to obtain the health care plan's compliance with this
section.
H. Absent a change in diagnosis or in a
subscriber's management or treatment of diabetes or its
complications, a health care plan shall not require more than
one prior authorization per plan period for any single drug
or category of item enumerated in this section if prescribed
as medically necessary by the subscriber's health care
practitioner. Changes in the prescribed dose of a drug;
quantities of supplies needed to administer a prescribed
drug; quantities of blood glucose self-testing equipment and
supplies; or quantities of supplies needed to use or operate
devices for which a subscriber has received prior
authorization during the plan year shall not be subject to
additional prior authorization requirements in the same plan
year if prescribed as medically necessary by the subscriber's
health care practitioner. Nothing in this subsection shall
be construed to require payment for diabetes resources that HB 233/a
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are not covered benefits.
I. The provisions of this section do not apply to:
(1) a short-term health care plan;
(2) an excepted benefit health care plan
intended to supplement major medical coverage, including
medicare supplement, vision, dental, disease-specific,
accident-only or hospital indemnity-only insurance policies;
(3) a policy or plan for long-term care or
disability income; or
(4) short-term travel policy or plan.
J. For purposes of this section, "basic health
care benefits":
(1) means benefits for medically necessary
services consisting of preventive care, emergency care,
inpatient and outpatient hospital and physician care,
diagnostic laboratory and diagnostic and therapeutic
radiological services; and
(2) does not include services for alcohol or
drug abuse, dental or long-term rehabilitation treatment."
SECTION 5. EFFECTIVE DATE.--The effective date of the
provisions of this act is January 1, 2026.