NM
New Mexico Senate Bill SB39

New Mexico 2025 Regular Session

New Mexico Senate Bill SB39 Compare Versions

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1-SB 39
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28+SENATE BILL 39
29+57TH LEGISLATURE - STATE OF NEW MEXICO - FIRST SESSION, 2025
30+INTRODUCED BY
31+Elizabeth "Liz" Stefanics and Reena Szczepanski
32+and Mimi Stewart and Carrie Hamblen
2833 AN ACT
29-RELATING TO INSURANCE; AMENDING THE PRIOR AUTHORIZATION ACT
30-TO ADD MORE CLASSES OF DRUGS THAT ARE NOT SUBJECT TO PRIOR
34+RELATING TO INSURANCE; AMENDING THE PRIOR AUTHORIZATION ACT TO
35+ADD MORE CLASSES OF DRUGS THAT ARE NOT SUBJECT TO PRIOR
3136 AUTHORIZATIONS OR STEP THERAPY PROTOCOLS.
3237 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
33-SECTION 1. Section 59A-22B-2 NMSA 1978 (being
34-Laws 2019, Chapter 187, Section 4) is amended to read:
35-"59A-22B-2. DEFINITIONS.--As used in the
36-Prior Authorization Act:
38+SECTION 1. Section 59A-22B-2 NMSA 1978 (being Laws 2019,
39+Chapter 187, Section 4) is amended to read:
40+"59A-22B-2. DEFINITIONS.--As used in the Prior
41+Authorization Act:
3742 A. "adjudicate" means to approve or deny a request
3843 for prior authorization;
3944 B. "auto-adjudicate" means to use technology and
4045 automation to make a near-real-time determination to approve,
4146 deny or pend a request for prior authorization;
4247 C. "covered person" means an individual who is
43-insured under a health benefits plan;
44-D. "emergency care" means medical care,
45-pharmaceutical benefits or related benefits to a covered
46-person after the sudden onset of what reasonably appears to
47-be a medical condition that manifests itself by symptoms of
48-sufficient severity, including severe pain, that the absence
49-of immediate medical attention could be reasonably expected
50-by a reasonable layperson to result in jeopardy to a person's
51-health, serious impairment of bodily functions, serious SB 39
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75+insured under a health benefits plan;
76+D. "emergency care" means medical care,
77+pharmaceutical benefits or related benefits to a covered person
78+after the sudden onset of what reasonably appears to be a
79+medical condition that manifests itself by symptoms of
80+sufficient severity, including severe pain, that the absence of
81+immediate medical attention could be reasonably expected by a
82+reasonable layperson to result in jeopardy to a person's
83+health, serious impairment of bodily functions, serious
7884 dysfunction of a bodily organ or part or disfigurement to a
7985 person;
80-E. "health benefits plan" means a policy,
81-contract, certificate or agreement, entered into, offered or
82-issued by a health insurer to provide, deliver, arrange for,
83-pay for or reimburse any of the costs of medical care,
84-pharmaceutical benefits or related benefits;
86+E. "health benefits plan" means a policy, contract,
87+certificate or agreement, entered into, offered or issued by a
88+health insurer to provide, deliver, arrange for, pay for or
89+reimburse any of the costs of medical care, pharmaceutical
90+benefits or related benefits;
8591 F. "health care professional" means an individual
86-who is licensed or otherwise authorized by the state to
87-provide health care services;
92+who is licensed or otherwise authorized by the state to provide
93+health care services;
8894 G. "health care provider" means a health care
8995 professional, corporation, organization, facility or
9096 institution licensed or otherwise authorized by the state to
9197 provide health care services;
9298 H. "health insurer" means a health maintenance
9399 organization, nonprofit health care plan, provider service
94-network, medicaid managed care organization or third-party
95-payer or its agent;
96-I. "medical care, pharmaceutical benefits or
97-related benefits" means medical, behavioral, hospital,
98-surgical, physical rehabilitation and home health services,
99-and includes pharmaceuticals, durable medical equipment,
100-prosthetics, orthotics and supplies;
101-J. "medical necessity" means health care services
102-determined by a health care provider, in consultation SB 39
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129-with the health insurer, to be appropriate or necessary
130-according to:
131-(1) applicable, generally accepted
132-principles and practices of good medical care;
128+network, medicaid managed care organization or third-party
129+payer or its agent;
130+I. "medical care, pharmaceutical benefits or
131+related benefits" means medical, behavioral, hospital,
132+surgical, physical rehabilitation and home health services, and
133+includes pharmaceuticals, durable medical equipment,
134+prosthetics, orthotics and supplies;
135+J. "medical necessity" means health care services
136+determined by a health care provider, in consultation with the
137+health insurer, to be appropriate or necessary according to:
138+(1) applicable, generally accepted principles
139+and practices of good medical care;
133140 (2) practice guidelines developed by the
134141 federal government or national or professional medical
135142 societies, boards or associations; or
136-(3) applicable clinical protocols or
137-practice guidelines developed by the health insurer
138-consistent with federal, national and professional practice
139-guidelines, which shall apply to the diagnosis, direct care
140-and treatment of a physical or behavioral health condition,
141-illness, injury or disease;
143+(3) applicable clinical protocols or practice
144+guidelines developed by the health insurer consistent with
145+federal, national and professional practice guidelines, which
146+shall apply to the diagnosis, direct care and treatment of a
147+physical or behavioral health condition, illness, injury or
148+disease;
142149 K. "medical peer review" means review by a health
143150 care professional from the same or similar practice specialty
144151 that typically manages the medical condition, procedure or
145152 treatment under review for prior authorization;
146-L. "off-label" means a federal food and drug
147-administration-approved medication that does not have a
148-federal food and drug administration-approved indication for
149-a specific condition or disease but is prescribed to a
150-covered person because there is sufficient clinical evidence
151-for a prescribing clinician to reasonably consider the
152-medication to be medically necessary to treat the covered
153-person's condition or disease; SB 39
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180-M. "office" means the office of superintendent of
181-insurance;
182-N. "pend" means to hold a prior authorization
181+L. "off-label" means a medication or a dosage of a
182+medication that is not approved by the federal food and drug
183+administration as a treatment for a specific condition or
184+disease but is prescribed to a covered person because there is
185+sufficient clinical evidence for a prescribing clinician to
186+reasonably consider the medication to be medically necessary to
187+treat the covered person's condition or disease;
188+[L.] M. "office" means the office of superintendent
189+of insurance;
190+[M.] N. "pend" means to hold a prior authorization
183191 request for further clinical review;
184-O. "pharmacy benefits manager" means an agent
192+[N.] O. "pharmacy benefits manager" means an agent
185193 responsible for handling prescription drug benefits for a
186-health insurer;
187-P. "prior authorization" means a voluntary or
194+health insurer; [and
195+O.] P. "prior authorization" means a voluntary or
188196 mandatory pre-service determination, including a recommended
189197 clinical review, that a health insurer makes regarding a
190-covered person's eligibility for health care services, based
191-on medical necessity, the appropriateness of the site of
192-services and the terms of the covered person's health
193-benefits plan; and
198+covered person's eligibility for health care services, based on
199+medical necessity, the appropriateness of the site of services
200+and the terms of the covered person's health benefits plan; and
194201 Q. "rare disease or condition" means a disease or
195202 condition that affects fewer than two hundred thousand people
196203 in the United States."
197-SECTION 2. Section 59A-22B-5 NMSA 1978 (being
198-Laws 2019, Chapter 187, Section 7) is amended to read:
199-"59A-22B-5. PRIOR AUTHORIZATION REQUIREMENTS.--
200-A. A health insurer that offers prior
201-authorization shall:
202-(1) use the uniform prior authorization
203-forms developed by the office for medical care, for
204-pharmaceutical benefits or related benefits pursuant to SB 39
205-Page 5
204+SECTION 2. Section 59A-22B-5 NMSA 1978 (being Laws 2019,
205+Chapter 187, Section 7) is amended to read:
206+.230346.2GLG
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231-Section 59A-22B-4 NMSA 1978 and for prescription drugs
234+"59A-22B-5. PRIOR AUTHORIZATION REQUIREMENTS.--
235+A. A health insurer that [requires ] offers prior
236+authorization shall:
237+(1) use the uniform prior authorization forms
238+developed by the office for medical care, for pharmaceutical
239+benefits or related benefits pursuant to Section [6 of this
240+2019 act] 59A-22B-4 NMSA 1978 and for prescription drugs
232241 pursuant to Section 59A-2-9.8 NMSA 1978;
233242 (2) establish and maintain an electronic
234243 portal system for:
235244 (a) the secure electronic transmission
236-of prior authorization requests on a twenty-four-hour,
237-seven-day-a-week basis, for medical care, pharmaceutical
238-benefits or related benefits; and
239-(b) auto-adjudication of prior
240-authorization requests;
245+of prior authorization requests on a twenty-four-hour, seven-
246+day-a-week basis, for medical care, pharmaceutical benefits or
247+related benefits; and
248+(b) [by January 1, 2021 ] auto-
249+adjudication of prior authorization requests;
241250 (3) provide an electronic receipt to the
242-health care provider and assign a tracking number to the
243-health care provider for the health care provider's use in
244-tracking the status of the prior authorization request,
245-regardless of whether or not the request is tracked
246-electronically, through a call center or by facsimile;
247-(4) auto-adjudicate all electronically
248-transmitted prior authorization requests to approve or pend a
249-request for benefits; and
250-(5) accept requests for medical care,
251-pharmaceutical benefits or related benefits that are not
252-electronically transmitted.
253-B. Prior authorization shall be deemed granted for
254-determinations not made within seven days; provided that:
255-(1) an adjudication shall be made within SB 39
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251+health care provider and assign a tracking number to the health
252+care provider for the health care provider's use in tracking
253+the status of the prior authorization request, regardless of
254+whether or not the request is tracked electronically, through a
255+call center or by facsimile;
256+(4) [by January 1, 2021 ] auto-adjudicate all
257+electronically transmitted prior authorization requests to
258+approve or pend a request for benefits; and
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287+(5) accept requests for medical care,
288+pharmaceutical benefits or related benefits that are not
289+electronically transmitted.
290+B. Prior authorization shall be deemed granted for
291+determinations not made within seven days; provided that:
292+(1) an adjudication shall be made within
282293 twenty-four hours, or shall be deemed granted if not made
283294 within twenty-four hours, when a covered person's health care
284295 professional requests an expedited prior authorization and
285296 submits to the health insurer a statement that, in the health
286-care professional's opinion that is based on reasonable
287-medical probability, delay in the treatment for which prior
297+care professional's opinion that is based on reasonable medical
298+probability, delay in the treatment for which prior
288299 authorization is requested could:
289300 (a) seriously jeopardize the covered
290301 person's life or overall health;
291302 (b) affect the covered person's ability
292303 to regain maximum function; or
293-(c) subject the covered person to
294-severe and intolerable pain; and
295-(2) the adjudication time line shall
296-commence only when the health insurer receives all necessary
297-and relevant documentation supporting the prior authorization
304+(c) subject the covered person to severe
305+and intolerable pain; and
306+(2) the adjudication time line shall commence
307+only when the health insurer receives all necessary and
308+relevant documentation supporting the prior authorization
298309 request.
299310 C. After December 31, 2020, an insurer may
300311 automatically deny a covered person's prior authorization
301-request that is electronically submitted and that relates to
302-a prescription drug that is not on the covered person's
303-health benefits plan formulary; provided that the insurer
304-shall accompany the denial with a list of alternative drugs
305-that are on the covered person's health benefits plan
306-formulary. SB 39
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340+request that is electronically submitted and that relates to a
341+prescription drug that is not on the covered person's health
342+benefits plan formulary; provided that the insurer shall
343+accompany the denial with a list of alternative drugs that are
344+on the covered person's health benefits plan formulary.
333345 D. Upon denial of a covered person's prior
334346 authorization request based on a finding that a prescription
335347 drug is not on the covered person's health benefits plan
336348 formulary, a health insurer shall notify the person of the
337349 denial and include in a conspicuous manner information
338350 regarding the person's right to initiate a drug formulary
339351 exception request and the process to file a request for an
340352 exception to the denial.
341353 E. An auto-adjudicated prior authorization request
342354 based on medical necessity that is pended or denied shall be
343355 reviewed by a health care professional who has knowledge or
344356 consults with a specialist who has knowledge of the medical
345357 condition or disease of the covered person for whom the
346-authorization is requested. The health care professional
347-shall make a final determination of the request. If the
348-request is denied after review by a health care professional,
349-notice of the denial shall be provided to the covered person
350-and covered person's provider with the grounds for the denial
351-and a notice of the right to appeal and describing the
352-process to file an appeal.
353-F. A health insurer shall establish a process by
354-which a health care provider or covered person may initiate
355-an electronic appeal of a denial of a prior authorization
356-request.
357-G. A health insurer shall have in place policies SB 39
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358+authorization is requested. The health care professional shall
359+make a final determination of the request. If the request is
360+denied after review by a health care professional, notice of
361+the denial shall be provided to the covered person and covered
362+person's provider with the grounds for the denial and a notice
363+of the right to appeal and describing the process to file an
364+appeal.
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393+F. A health insurer shall establish a process by
394+which a health care provider or covered person may initiate an
395+electronic appeal of a denial of a prior authorization request.
396+G. A health insurer shall have in place policies
384397 and procedures for annual review of its prior authorization
385-practices to validate that the prior authorization
386-requirements advance the principles of lower cost and
387-improved quality, safety and service.
388-H. The office shall establish by rule protocols
389-and criteria pursuant to which a covered person or a covered
390-person's health care professional may request expedited
391-independent review of an expedited prior authorization
392-request made pursuant to Subsection B of this section
393-following medical peer review of a prior authorization
394-request pursuant to the Prior Authorization Act."
395-SECTION 3. Section 59A-22B-8 NMSA 1978 (being
396-Laws 2023, Chapter 114, Section 13, as amended) is amended to
397-read:
398-"59A-22B-8. PRIOR AUTHORIZATION FOR PRESCRIPTION DRUGS
399-OR STEP THERAPY FOR CERTAIN CONDITIONS PROHIBITED.--
398+practices to validate that the prior authorization requirements
399+advance the principles of lower cost and improved quality,
400+safety and service.
401+H. The office [of superintendent of insurance ]
402+shall establish by rule protocols and criteria pursuant to
403+which a covered person or a covered person's health care
404+professional may request expedited independent review of an
405+expedited prior authorization request made pursuant to
406+Subsection B of this section following medical peer review of a
407+prior authorization request pursuant to the Prior Authorization
408+Act."
409+SECTION 3. Section 59A-22B-8 NMSA 1978 (being Laws 2023,
410+Chapter 114, Section 13, as amended) is amended to read:
411+"59A-22B-8. PRIOR AUTHORIZATION FOR PRESCRIPTION DRUGS OR
412+STEP THERAPY FOR CERTAIN CONDITIONS PROHIBITED.--
400413 A. Coverage for medication approved by the federal
401414 food and drug administration that is prescribed for the
402415 treatment of an autoimmune disorder, cancer, rare disease or
403416 condition or a substance use disorder, pursuant to a medical
404-necessity determination made by a health care professional
405-from the same or similar practice specialty that typically
406-manages the medical condition, procedure or treatment under
407-review, shall not be subject to prior authorization, except
408-in cases in which a biosimilar, interchangeable biologic or SB 39
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417+necessity determination made by a health care professional from
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435-generic version is available. Medical necessity
436-determinations shall be automatically approved within
437-seven days for standard determinations and twenty-four hours
438-for emergency determinations when a delay in treatment could:
446+the same or similar practice specialty that typically manages
447+the medical condition, procedure or treatment under review ,
448+shall not be subject to prior authorization, except in cases in
449+which a biosimilar, interchangeable biologic or generic version
450+is available. Medical necessity determinations shall be
451+automatically approved within seven days for standard
452+determinations and twenty-four hours for emergency
453+determinations when a delay in treatment could:
439454 (1) seriously jeopardize a covered person's
440455 life or overall health;
441456 (2) affect a covered person's ability to
442457 regain maximum function; or
443458 (3) subject a covered person to severe and
444459 intolerable pain.
445460 B. A health insurer shall not impose step therapy
446461 requirements before authorizing coverage for medication
447462 approved by the federal food and drug administration that is
448-prescribed for the treatment of an autoimmune disorder,
449-cancer or a substance use disorder, pursuant to a medical
450-necessity determination made by a health care professional
451-from the same or similar practice specialty that typically
452-manages the medical condition, procedure or treatment under
453-review, except in cases in which a biosimilar,
454-interchangeable biologic or generic version is available.
463+prescribed for the treatment of an autoimmune disorder, cancer
464+or a substance use disorder, pursuant to a medical necessity
465+determination made by a health care professional from the same
466+or similar practice specialty that typically manages the
467+medical condition, procedure or treatment under review , except
468+in cases in which a biosimilar, interchangeable biologic or
469+generic version is available.
455470 C. A health insurer shall not impose step therapy
456-requirements before authorizing coverage for an off-label
457-medication that is prescribed for the treatment of a rare
458-disease or condition, pursuant to a medical necessity
459-determination made by a health care professional from the SB 39
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486-same or similar practice specialty that typically manages the
487-medical condition, procedure or treatment under review,
488-except in cases in which a biosimilar, interchangeable
489-biologic or generic version is available. Medical necessity
490-determinations shall be automatically approved within seven
491-days for standard determinations and twenty-four hours for
492-emergency determinations when a delay in treatment could:
499+requirements before authorizing coverage for an off-label
500+medication that is prescribed for the treatment of a rare
501+disease or condition, pursuant to a medical necessity
502+determination made by a health care professional from the same
503+or similar practice specialty that typically manages the
504+medical condition, procedure or treatment under review, except
505+in cases in which a biosimilar, interchangeable biologic or
506+generic version is available. Medical necessity determinations
507+shall be automatically approved within seven days for standard
508+determinations and twenty-four hours for emergency
509+determinations when a delay in treatment could:
493510 (1) seriously jeopardize a covered person's
494511 life or overall health;
495512 (2) affect a covered person's ability to
496513 regain maximum function; or
497514 (3) subject a covered person to severe and
498515 intolerable pain."
499516 SECTION 4. APPLICABILITY.--The provisions of this act
500517 apply to an individual or group policy, contract, certificate
501518 or agreement to provide, deliver, arrange for, pay for or
502519 reimburse any of the costs of medical care, pharmaceutical
503520 benefits or related benefits that is entered into, offered or
504521 issued by a health insurer on or after July 1, 2025, pursuant
505522 to any of the following:
506523 A. Chapter 59A, Article 22 NMSA 1978;
524+.230346.2GLG
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507552 B. Chapter 59A, Article 23 NMSA 1978;
508553 C. the Health Maintenance Organization Law;
509554 D. the Nonprofit Health Care Plan Law; or
510555 E. the Health Care Purchasing Act.
556+- 11 -
557+.230346.2GLG