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SENATE BILL 508
57
TH LEGISLATURE
-
STATE
OF
NEW
MEXICO
-
FIRST SESSION
,
2025
INTRODUCED BY
Heather Berghmans and Carrie Hamblen and Angel M. Charley
and Micaelita Debbie O’Malley and Mimi Stewart
AN ACT
RELATING TO INSURANCE; AMENDING AND ENACTING SECTIONS OF THE
HEALTH CARE PURCHASING ACT, THE PUBLIC ASSISTANCE ACT AND THE
NEW MEXICO INSURANCE CODE TO REQUIRE COVERAGE FOR CERTAIN
SEXUAL, REPRODUCTIVE AND GENDER-AFFIRMING HEALTH CARE SERVICES;
TO ELIMINATE COST SHARING FOR CERTAIN SEXUAL, REPRODUCTIVE AND
GENDER-AFFIRMING HEALTH CARE SERVICES; AND TO ELIMINATE PRIOR
AUTHORIZATION REQUIREMENTS FOR CERTAIN SEXUAL, REPRODUCTIVE AND
GENDER-AFFIRMING HEALTH CARE SERVICES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. A new section of the Health Care Purchasing
Act is enacted to read:
"[NEW MATERIAL] PREVENTIVE BENEFITS--NO COST SHARING.--
Group health coverage, including any form of self-insurance,
offered, issued or renewed under the Health Care Purchasing Act
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shall provide coverage for and shall not impose any
cost-sharing requirements for:
A. items or services that have in effect a rating
of "A" or "B" in the current recommendations of the United
States preventive services task force;
B. immunizations that have in effect a
recommendation from the advisory committee on immunization
practices of the federal centers for disease control and
prevention, with respect to the insured for which immunization
is considered;
C. with respect to infants, children and
adolescents, preventive care and screenings provided for in the
comprehensive guidelines supported by the health resources and
services administration of the United States department of
health and human services; and
D. with respect to women, additional preventive
care and screenings to those described in Subsection A of this
section, as provided for in comprehensive guidelines supported
by the health resources and services administration of the
United States department of health and human services."
SECTION 2. A new section of the Health Care Purchasing
Act is enacted to read:
"[NEW MATERIAL] ABORTION CARE--NO COST SHARING.--
A. Except as provided in Subsection C of this
section, all group health coverage, including self-insurance,
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offered, issued, amended, delivered or renewed under the Health
Care Purchasing Act shall provide coverage for the total cost
of abortion care.
B. The coverage shall not be subject to cost
sharing.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
this state until an eligible insured's deductible has been
met."
SECTION 3. A new section of the Health Care Purchasing
Act is enacted to read:
"[NEW MATERIAL] PREGNANCY--SPECIAL ENROLLMENT PERIOD.--
A. Group health coverage, including self-insurance,
offered, issued, amended, delivered or renewed under the Health
Care Purchasing Act shall establish a special enrollment period
to provide coverage to an uninsured person when the person
provides a certification from a health care provider to the
insurer that the person is pregnant.
B. Coverage shall be effective before the end of
the first month in which the uninsured person receives
certification of the pregnancy, unless the person elects to
have coverage effective on the first day of the month following
the date that the person makes a plan selection."
SECTION 4. A new section of the Health Care Purchasing
Act is enacted to read:
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"[NEW MATERIAL] COVERAGE FOR GENDER-AFFIRMING CARE.--
A. All group health coverage, including self-
insurance, offered, issued, amended, delivered or renewed under
the Health Care Purchasing Act shall provide coverage for
gender-affirming care.
B. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
identity and the individual's sex assignment at birth.
C. The provisions of Subsection A of this section
do not apply to a high deductible health benefit plan issued or
renewed in this state until an eligible insured's deductible
has been met, unless allowed pursuant to federal law."
SECTION 5. Section 13-7-22 NMSA 1978 (being Laws 2019,
Chapter 263, Section 1) is amended to read:
"13-7-22. COVERAGE FOR CONTRACEPTION.--
A. Group health coverage, including any form of
self-insurance, offered, issued or renewed under the Health
Care Purchasing Act that provides coverage for prescription
drugs shall provide, at a minimum, the following coverage:
(1) at least one product or form of
contraception in each of the contraceptive method categories
identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral
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contraceptive pills to reflect the variety of oral
contraceptives approved by the federal food and drug
administration; and
(3) clinical services related to the provision
or use of contraception, including consultations, examinations,
procedures, ultrasound, anesthesia, patient education,
counseling, device insertion and removal, follow-up care and
side-effects management.
B. Except as provided in Subsection C of this
section, the coverage required pursuant to this section shall
not be subject to:
(1) enrollee cost sharing;
(2) utilization review;
(3) prior authorization or step therapy
requirements; or
(4) any other restrictions or delays on the
coverage.
C. A group health plan may discourage brand-name
pharmacy drugs or items by applying cost sharing to brand-name
drugs or items when at least one generic or therapeutic
equivalent is covered within the same method of contraception
without patient cost sharing; provided that when an enrollee's
health care provider determines that a particular drug or item
is medically necessary, the group health plan shall cover the
brand-name pharmacy drug or item without cost sharing. Medical
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necessity may include considerations such as severity of side
effects, differences in permanence or reversibility of
contraceptives and ability to adhere to the appropriate use of
the drug or item, as determined by the attending provider.
D. A group health plan administrator shall grant an
enrollee an expedited hearing to appeal any adverse
determination made relating to the provisions of this section.
The process for requesting an expedited hearing pursuant to
this subsection shall:
(1) be easily accessible, transparent,
sufficiently expedient and not unduly burdensome on an
enrollee, the enrollee's representative or the enrollee's
health care provider;
(2) defer to the determination of the
enrollee's health care provider; and
(3) provide for a determination of the claim
according to a time frame and in a manner that takes into
account the nature of the claim and the medical exigencies
involved for a claim involving an urgent health care need.
E. A group health plan shall not require a
prescription for any drug, item or service that is available
without a prescription.
F. A group health plan shall provide coverage and
shall reimburse a health care provider or dispensing entity on
a per-unit basis for dispensing [a six-month supply of
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contraceptives] contraception intended to last the enrollee for
a duration of twelve months, as permitted by the enrollee's
prescription, dispensed at one time; provided that the
contraceptives are prescribed and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to
prescribe six months of contraceptives at one time; or
(2) permit a group health plan to limit
coverage or impose cost sharing for an alternate method of
contraception if an enrollee changes contraceptive methods
before exhausting a previously dispensed supply.
H. The provisions of this section shall not apply
to short-term travel, accident-only, hospital-indemnity-only,
limited-benefit or disease-specific group health plans.
I. For the purposes of this section:
(1) "contraceptive method categories
identified by the federal food and drug administration":
(a) means tubal ligation; sterilization
implant; copper intrauterine device; intrauterine device with
progestin; implantable rod; contraceptive shot or injection;
combined oral contraceptives; extended or continuous use oral
contraceptives; progestin-only oral contraceptives; patch;
vaginal ring; diaphragm with spermicide; sponge with
spermicide; cervical cap with spermicide; male and female
condoms; spermicide alone; vasectomy; ulipristal acetate;
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levonorgestrel emergency contraception; and any additional
method categories of contraception approved by the federal food
and drug administration; and
(b) does not mean a product that has
been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible,
copayment or coinsurance that an enrollee is required to pay in
accordance with the terms of a group health plan; and
(3) "health care provider" means an individual
licensed to provide health care in the ordinary course of
business."
SECTION 6. Section 27-2-12.29 NMSA 1978 (being Laws 2019,
Chapter 263, Section 2) is amended to read:
"27-2-12.29. MEDICAL ASSISTANCE--REIMBURSEMENT FOR A ONE-
YEAR SUPPLY OF COVERED PRESCRIPTION CONTRACEPTIVE DRUGS OR
DEVICES.--
A. In providing coverage for family planning
services and supplies under the medical assistance program, the
[department] authority shall ensure that a recipient is
permitted to fill or refill a prescription for a one-year
supply of a covered, self-administered contraceptive at one
time, as prescribed.
B. Nothing in this section shall be construed to
limit a recipient's freedom to choose or change the method of
family planning to be used, regardless of whether the recipient
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has exhausted a previously dispensed supply of contraceptives.
C. Nothing in this section shall be construed to:
(1) require a health care provider to
prescribe twelve months of contraceptives at one time;
(2) permit the authority or a managed care
organization to impose any restrictions or delays on coverage,
including quantity or fill limits, if the practice would result
in a covered person receiving less than a twelve-months'
duration of contraception dispensed either at one time or, if
requested by the covered person at the point of dispensing,
over a twelve-month period;
(3) permit the authority or a managed care
organization to limit coverage or impose cost sharing for an
alternative method of contraception if a patient changes
contraceptive methods before exhausting a previously dispensed
supply of contraceptives;
(4) permit the authority or a managed care
organization to limit the quantity of contraceptive drugs or
devices dispensed; or
(5) permit the authority or a managed care
organization to deny coverage for the continuous use of
clinically appropriate contraception as determined by the
prescribing provider.
D. For the purposes of this section, "self-
administered contraceptive" means combined oral contraceptives;
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extended or continuous use oral contraceptives; progestin-only
oral contraceptives; patch; vaginal ring; diaphragm with
spermicide; sponge with spermicide; cervical cap with
spermicide; male and female condoms; spermicide alone;
ulipristal acetate; levonorgestrel emergency contraception; and
any other self-administered contraceptive method categories
approved by the federal food and drug administration. "
SECTION 7. A new section of the Public Assistance Act is
enacted to read:
"[NEW MATERIAL] FAMILY PLANNING AND RELATED SERVICES.--
A. When family planning services or family-
planning-related services are provided in accordance with the
Public Assistance Act, the authority shall authorize
reimbursement for services without quantity limitation,
utilization controls or prior authorization. The authority,
any intermediaries or any managed care organization shall
reimburse the provider of those services.
B. As used in this section:
(1) "family-planning-related services" means
any medical diagnosis, treatment or preventive service that is
routinely provided pursuant to a family planning visit,
including:
(a) abortion care;
(b) miscarriage management;
(c) medically necessary evaluations or
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preventive services, such as tobacco utilization screening,
counseling, testing, and cessation services;
(d) cervical cancer screening and
prevention;
(e) prevention, diagnosis or treatment
of a sexually transmitted infection or sexually transmitted
disease; and
(f) mental health screening and
referral; and
(2) "family planning services" means all
services covered by the federal Title X family planning
program, regardless of an individual's or a partner's age, sex
or gender identity, including:
(a) all contraceptive method categories
approved by the federal food and drug administration,
including: 1) tubal ligation; 2) sterilization implant; 3)
copper intrauterine device; 4) intrauterine device with
progestin; 5) implantable rod; 6) contraceptive injection; 7)
combined oral contraceptives; 8) extended or continuous use
oral contraceptives; 9) progestin-only oral contraceptives; 10)
patch; 11) vaginal ring; 12) diaphragm with spermicide; 13)
sponge with spermicide; 14) cervical cap with spermicide; 15)
male and female condoms; 16) spermicide alone; 17) vasectomy;
18) ulipristal acetate; and 19) levonorgestrel emergency
contraception;
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(b) health care and counseling services
focused on preventing, delaying or planning for a pregnancy;
(c) follow-up visits to evaluate or
manage problems associated with contraceptive methods; and
(d) basic fertility services.
C. A recipient shall be permitted to obtain family
planning services or family-planning-related services from any
licensed health care provider, including a doctor of medicine,
a doctor of osteopathy, a physician assistant, an advanced
practice registered nurse or a certified midwife. The
enrollment of a recipient in a managed care organization shall
not restrict a recipient's choice of the licensed provider from
whom the recipient may receive those services or restrict the
obligation of the managed care organization to reimburse the
provider of those services.
D. When abortion care services are provided in
accordance with the Public Assistance Act, the authority, any
intermediaries or any managed care organization shall reimburse
the provider of those services as distinct, non-bundled
procedural services and shall allow modifier codes, including
increased professional service, distinct procedural services
and separate structures, to reflect the increased time and
training required when applicable."
SECTION 8. A new section of the Public Assistance Act is
enacted to read:
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"[NEW MATERIAL] LACTATION SUPPORT.--
A. The authority shall ensure that medical
assistance coverage, including coverage provided by any managed
care organizations, provides coverage for lactation support,
including:
(1) prior to delivery, single user lactation
supplies and equipment; and
(2) comprehensive lactation support services
provided by a lactation care provider licensed pursuant to the
Lactation Care Provider Act.
B. Access to multi-user loaned breast pumps shall
be prioritized for persons with premature, medically fragile,
low birth weight infants or with lactation complications.
Access to multi-user loaned breast pumps shall be authorized by
a health care provider."
SECTION 9. A new section of the Public Assistance Act is
enacted to read:
"[NEW MATERIAL] GENDER-AFFIRMING CARE.--
A. The authority shall ensure that medical
assistance coverage, including coverage provided by any managed
care organizations, provides coverage for gender-affirming
care.
B. Coverage provided pursuant to this section:
(1) may be subject to other general exclusions
and limitations of medical assistance coverage, including
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coordination of benefits, participating provider requirements
and restrictions on services provided by family or household
members; and
(2) shall not be subject to cost-sharing
provisions.
C. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
identity and the individual's sex assignment at birth."
SECTION 10. A new section of Chapter 59A, Article 22
NMSA 1978 is enacted to read:
"[NEW MATERIAL] ABORTION CARE--NO COST SHARING.--
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 the total cost of abortion care.
B. The coverage shall not be subject to cost
sharing.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
this state until an eligible insured's deductible has been
met."
SECTION 11. Section 59A-22-42 NMSA 1978 (being Laws
2001, Chapter 14, Section 1, as amended) is amended to read:
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"59A-22-42. COVERAGE FOR PRESCRIPTION CONTRACEPTIVE
DRUGS OR DEVICES.--
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 form of
contraception in each of the contraceptive method categories
identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral
contraceptive pills to reflect the variety of oral
contraceptives approved by the federal food and drug
administration; [and]
(3) clinical services related to the provision
or use of contraception, including consultations, examinations,
procedures, ultrasound, anesthesia, patient education,
counseling, device insertion and removal, follow-up care and
side-effects management;
(4) a sufficient quantity to allow for the
continuous use of clinically appropriate contraception as
determined by the prescribing provider; and
(5) United States food and drug
administration-approved, -cleared or -granted over-the-counter
contraception, including point-of-sale coverage for
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over-the-counter contraception at in-network dispensing
entities without prior authorization, step therapy, utilization
management or cost sharing .
B. Except as provided in Subsection C of this
section, the coverage required pursuant to this section shall
not be subject to:
(1) cost sharing for insureds;
(2) utilization review;
(3) prior authorization or step-therapy
requirements; or
(4) any other restrictions or delays on the
coverage, including quantity or fill limits if the practice
would result in a covered person receiving less than a
twelve-months' duration of contraception dispensed either at
one time or, if requested by the covered person at the point of
dispensing, over a twelve-month period .
C. An insurer may discourage brand-name pharmacy
drugs or items by applying cost sharing to brand-name drugs or
items when at least one generic or therapeutic equivalent is
covered within the same method of contraception without patient
cost sharing; provided that when an insured's health care
provider determines that a particular drug or item is medically
necessary, the individual or group health insurance policy,
health care plan or certificate of insurance shall cover the
brand-name pharmacy drug or item without cost sharing. Medical
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necessity may include considerations such as severity of side
effects, differences in permanence or reversibility of
contraceptives and ability to adhere to the appropriate use of
the drug or item, as determined by the attending provider.
D. An insurer shall grant an insured an expedited
hearing to appeal any adverse determination made relating to
the provisions of this section. The process for requesting an
expedited hearing pursuant to this subsection shall:
(1) be easily accessible, transparent,
sufficiently expedient and not unduly burdensome on an insured,
the insured's representative or the insured's health care
provider;
(2) defer to the determination of the
insured's health care provider; and
(3) provide for a determination of the claim
according to a time frame and in a manner that takes into
account the nature of the claim and the medical exigencies
involved for a claim involving an urgent health care need.
E. An insurer shall not require a prescription for
any drug, item or service that is available without a
prescription.
F. An insurer shall provide coverage and shall
reimburse a health care provider or dispensing entity on a per-
unit basis for dispensing [a six-month supply of
contraceptives] contraception intended to last the covered
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person for a duration of twelve months, as permitted by the
covered person's prescription, dispensed at one time; provided
that the contraceptives are prescribed and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to
prescribe [six] twelve months of contraceptives at one time;
[or]
(2) permit an insurer to limit coverage or
impose cost sharing for an alternate method of contraception if
an insured changes contraceptive methods before exhausting a
previously dispensed supply;
(3) permit an insurer to limit the quantity of
contraceptives dispensed based on the number of months left in
the plan year; or
(4) permit an insurer or pharmacy benefits
manager to deny coverage for the continuous use of clinically
appropriate contraception as determined by the prescribing
provider.
H. The provisions of this section shall not apply
to short-term travel, accident-only, hospital-indemnity-only,
limited-benefit or specified-disease policies.
I. The provisions of this section apply to
individual and group health insurance policies, health care
plans and certificates of insurance delivered or issued for
delivery after January 1, 2020.
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J. For the purposes of this section:
(1) "contraceptive method categories
identified by the federal food and drug administration":
(a) means tubal ligation; sterilization
implant; copper intrauterine device; intrauterine device with
progestin; implantable rod; contraceptive shot or injection;
combined oral contraceptives; extended or continuous use oral
contraceptives; progestin-only oral contraceptives; patch;
vaginal ring; diaphragm with spermicide; sponge with
spermicide; cervical cap with spermicide; male and female
condoms; spermicide alone; vasectomy; ulipristal acetate;
levonorgestrel emergency contraception; and any additional
contraceptive method categories approved by the federal food
and drug administration; and
(b) does not mean a product that has
been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible,
copayment or coinsurance that an insured is required to pay in
accordance with the terms of an individual or group health
insurance policy, health care plan or certificate of insurance;
and
(3) "health care provider" means an individual
licensed to provide health care in the ordinary course of
business.
K. A religious entity purchasing individual or
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group health insurance coverage may elect to exclude
prescription contraceptive drugs or devices from the health
coverage purchased."
SECTION 12. A new section of Chapter 59A, Article 22
NMSA 1978 is enacted to read:
"[NEW MATERIAL] SPECIAL ENROLLMENT PERIOD--PREGNANCY.--
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
establish a special enrollment period to provide coverage to an
uninsured person when the person provides a certification from
a health care provider to the insurer that the person is
pregnant.
B. Coverage shall be effective before the end of
the first month in which the person receives certification of
the pregnancy, unless the person elects to have coverage
effective on the first day of the month following the date that
the person makes a plan selection."
SECTION 13. A new section of Chapter 59A, Article 22
NMSA 1978 is enacted to read:
"[NEW MATERIAL] COVERAGE FOR GENDER-AFFIRMING CARE.--
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 gender-affirming care.
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B. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
identity and the individual's sex assignment at birth.
C. The provisions of this section do not apply to a
high deductible health benefit plan issued or renewed in this
state until an eligible insured's deductible has been met."
SECTION 14. A new section of Chapter 59A, Article 23
NMSA 1978 is enacted to read:
"[NEW MATERIAL] ABORTION CARE--NO COST SHARING.--
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
provide coverage for the total cost of abortion care.
B. The coverage shall not be subject to cost
sharing.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
this state until an eligible insured's deductible has been
met."
SECTION 15. Section 59A-23-7.14 NMSA 1978 (being Laws
2019, Chapter 263, Section 5) is amended to read:
"59A-23-7.14. COVERAGE FOR CONTRACEPTION.--
A. [Each individual and group ] A group or blanket
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health insurance policy, health care plan [and ] or certificate
of health insurance that is delivered, [or] issued for delivery
or renewed in this state that provides a prescription drug
benefit shall provide, at a minimum, the following coverage:
(1) at least one product or form of
contraception in each of the contraceptive method categories
identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral
contraceptive pills to reflect the variety of oral
contraceptives approved by the federal food and drug
administration; [and]
(3) clinical services related to the provision
or use of contraception, including consultations, examinations,
procedures, ultrasound, anesthesia, patient education,
counseling, device insertion and removal, follow-up care and
side-effects management;
(4) a sufficient quantity to allow for the
continuous use of clinically appropriate contraception as
determined by the prescribing provider; and
(5) United States food and drug
administration-approved, -cleared or -granted over-the-counter
contraception, including point-of-sale coverage for
over-the-counter contraception at in-network dispensing
entities without prior authorization, step therapy, utilization
management or cost sharing .
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B. [Except as provided in Subsection C of this
section] The coverage required pursuant to this section shall
not be subject to:
(1) cost sharing for insureds;
(2) utilization review;
(3) prior authorization or step-therapy
requirements; or
(4) any restrictions or delays on the
coverage.
C. An insurer may discourage brand-name pharmacy
drugs or items by applying cost sharing to brand-name drugs or
items when at least one generic or therapeutic equivalent is
covered within the same method category of contraception
without cost sharing by the insured; provided that when an
insured's health care provider determines that a particular
drug or item is medically necessary, the individual or group
health insurance policy, health care plan or certificate of
health insurance shall cover the brand-name pharmacy drug or
item without cost sharing. A determination of medical
necessity may include considerations such as severity of side
effects, differences in permanence or reversibility of
contraceptives and ability to adhere to the appropriate use of
the drug or item, as determined by the attending provider.
D. An insurer shall grant an insured an expedited
hearing to appeal any adverse determination made relating to
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the provisions of this section. The process for requesting an
expedited hearing pursuant to this subsection shall:
(1) be easily accessible, transparent,
sufficiently expedient and not unduly burdensome on an insured,
the insured's representative or the insured's health care
provider;
(2) defer to the determination of the
insured's health care provider; and
(3) provide for a determination of the claim
according to a time frame and in a manner that takes into
account the nature of the claim and the medical exigencies
involved for a claim involving an urgent health care need.
E. An insurer shall not require a prescription for
any drug, item or service that is available without a
prescription.
F. An individual or group health insurance policy,
health care plan or certificate of health insurance shall
provide coverage and shall reimburse a health care provider or
dispensing entity on a per unit basis for dispensing [a six-
month supply of contraceptives ] contraception intended to last
the covered person for a duration of twelve months, as
permitted by the covered person's prescription, dispensed at
one time; provided that the contraceptives are prescribed and
self-administered.
G. Nothing in this section shall be construed to:
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(1) require a health care provider to
prescribe [six] twelve months of contraceptives at one time;
[or]
(2) permit an insurer to limit coverage or
impose cost sharing for an alternate method of contraception if
an insured changes contraceptive methods before exhausting a
previously dispensed supply;
(3) permit an insurer to limit the quantity of
contraceptives dispensed based on the number of months left in
the plan year; or
(4) permit an insurer to deny coverage for the
continuous use of clinically appropriate contraception as
determined by the prescribing provider .
H. The provisions of this section shall not apply
to short-term travel, accident-only, hospital-indemnity-only,
limited-benefit or specified-disease health benefits plans.
I. The provisions of this section apply to
individual or group health insurance policies, health care
plans or certificates of insurance delivered or issued for
delivery after January 1, 2020.
J. For the purposes of this section:
(1) "contraceptive method categories
identified by the federal food and drug administration":
(a) means tubal ligation; sterilization
implant; copper intrauterine device; intrauterine device with
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progestin; implantable rod; contraceptive shot or injection;
combined oral contraceptives; extended or continuous use oral
contraceptives; progestin-only oral contraceptives; patch;
vaginal ring; diaphragm with spermicide; sponge with
spermicide; cervical cap with spermicide; male and female
condoms; spermicide alone; vasectomy; ulipristal acetate;
levonorgestrel emergency contraception; and any additional
contraceptive method categories approved by the federal food
and drug administration; and
(b) does not mean a product that has
been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible,
copayment or coinsurance that an insured is required to pay in
accordance with the terms of an individual or group health
insurance policy, health care plan or certificate of insurance;
and
(3) "health care provider" means an individual
licensed to provide health care in the ordinary course of
business.
K. A religious entity purchasing individual or
group health insurance coverage may elect to exclude
prescription contraceptive drugs or items from the health
insurance coverage purchased."
SECTION 16. A new section of Chapter 59A, Article 23
NMSA 1978 is enacted to read:
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"[NEW MATERIAL] SPECIAL ENROLLMENT PERIOD--PREGNANCY.--
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
establish a special enrollment period to provide coverage to an
uninsured person when the person provides a certification from
a health care provider to the insurer that the person is
pregnant.
B. Coverage shall be effective before the end of
the first month in which the uninsured person receives
certification of the pregnancy, unless the person elects to
have coverage effective on the first day of the month following
the date that the person makes a plan selection."
SECTION 17. A new section of Chapter 59A, Article 23
NMSA 1978 is enacted to read:
"[NEW MATERIAL] COVERAGE FOR GENDER-AFFIRMING CARE.--
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
provide coverage for gender-affirming care.
B. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
identity and the individual's sex assignment at birth.
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C. The provisions of this section shall not apply
to a high deductible health benefit plans issued or renewed in
this state until an eligible insured's deductible has been
met."
SECTION 18. A new section of the Health Maintenance
Organization Law is enacted to read:
"[NEW MATERIAL] ABORTION CARE--NO COST SHARING.--
A. An individual or group health maintenance
organization contract that is delivered, issued for delivery or
renewed in this state shall provide coverage for the total cost
of abortion care.
B. The coverage shall not be subject to cost
sharing.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
this state until an eligible insured's deductible has been
met."
SECTION 19. Section 59A-46-44 NMSA 1978 (being Laws
2001, Chapter 14, Section 3, as amended) is amended to read:
"59A-46-44. COVERAGE FOR CONTRACEPTION.--
A. [Each] An individual and group health
maintenance organization contract 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 form of
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contraception in each of the contraceptive method categories
identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral
contraceptive pills to reflect the variety of oral
contraceptives approved by the federal food and drug
administration; [and]
(3) clinical services related to the provision
or use of contraception, including consultations, examinations,
procedures, ultrasound, anesthesia, patient education,
counseling, device insertion and removal, follow-up care and
side-effects management;
(4) sufficient quantity to allow for the
continuous use of clinically appropriate contraception as
determined by the prescribing provider; and
(5) United States food and drug
administration-approved, -cleared or -granted over-the-counter
contraception, including point-of-sale coverage for
over-the-counter contraception at in-network dispensing
entities without prior authorization, step therapy, utilization
management or cost sharing .
B. Except as provided in Subsection C of this
section, the coverage required pursuant to this section shall
not be subject to:
(1) enrollee cost sharing;
(2) utilization review;
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(3) prior authorization or step-therapy
requirements; or
(4) any other restrictions or delays on the
coverage, including quantity or fill limits if the practice
would result in a covered person receiving less than a
twelve-months' duration of contraception dispensed either at
one time or, if requested by the covered person at the point of
dispensing, over a twelve-month period .
C. A health maintenance organization may discourage
brand-name pharmacy drugs or items by applying cost sharing to
brand-name drugs or items when at least one generic or
therapeutic equivalent is covered within the same method of
contraception without patient cost sharing; provided that when
an enrollee's health care provider determines that a particular
drug or item is medically necessary, the individual or group
health maintenance organization contract shall cover the brand-
name pharmacy drug or item without cost sharing. Medical
necessity may include considerations such as severity of side
effects, differences in permanence or reversibility of
contraceptives and ability to adhere to the appropriate use of
the drug or item, as determined by the attending provider.
D. An individual or group health maintenance
organization contract shall grant an enrollee an expedited
hearing to appeal any adverse determination made relating to
the provisions of this section. The process for requesting an
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expedited hearing pursuant to this subsection shall:
(1) be easily accessible, transparent,
sufficiently expedient and not unduly burdensome on an
enrollee, the enrollee's representative or the enrollee's
health care provider;
(2) defer to the determination of the
enrollee's health care provider; and
(3) provide for a determination of the claim
according to a time frame and in a manner that takes into
account the nature of the claim and the medical exigencies
involved for a claim involving an urgent health care need.
E. An individual or group health maintenance
organization contract shall not require a prescription for any
drug, item or service that is available without a prescription.
F. An individual or group health maintenance
organization contract shall provide coverage and shall
reimburse a health care provider or dispensing entity on a per-
unit basis for dispensing a six-month supply of contraceptives
at one time; provided that the contraceptives are prescribed
and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to
prescribe six months of contraceptives at one time; or
(2) permit an individual or group health
maintenance organization contract to limit coverage or impose
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cost sharing for an alternate method of contraception if an
enrollee changes contraceptive methods before exhausting a
previously dispensed supply.
H. The provisions of this section shall not apply
to short-term travel, accident-only, hospital-indemnity-only,
limited-benefit or specified disease health benefits plans.
I. The provisions of this section apply to
individual or group health maintenance organization contracts
delivered or issued for delivery after January 1, 2020.
J. For the purposes of this section:
(1) "contraceptive method categories
identified by the federal food and drug administration":
(a) means tubal ligation; sterilization
implant; copper intrauterine device; intrauterine device with
progestin; implantable rod; contraceptive shot or injection;
combined oral contraceptives; extended or continuous use oral
contraceptives; progestin-only oral contraceptives; patch;
vaginal ring; diaphragm with spermicide; sponge with
spermicide; cervical cap with spermicide; male and female
condoms; spermicide alone; vasectomy; ulipristal acetate;
levonorgestrel emergency contraception; and any additional
contraceptive method categories approved by the federal food
and drug administration; and
(b) does not mean a product that has
been recalled for safety reasons or withdrawn from the market;
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(2) "cost sharing" means a deductible,
copayment or coinsurance that an enrollee is required to pay in
accordance with the terms of an individual or group health
maintenance organization contract; and
(3) "health care provider" means an individual
licensed to provide health care in the ordinary course of
business.
K. A religious entity purchasing individual or
group health maintenance organization coverage may elect to
exclude prescription contraceptive drugs or devices from the
health coverage purchased."
SECTION 20. A new section of the Health Maintenance
Organization Law is enacted to read:
"[NEW MATERIAL] SPECIAL ENROLLMENT PERIOD--PREGNANCY.--
A. An individual or group health maintenance
organization contract delivered or issued for delivery in this
state shall establish a special enrollment period to provide
coverage to an uninsured person when the person provides a
certification from a health care provider to the insurer that
the person is pregnant.
B. Coverage shall be effective before the end of
the first month in which the person receives certification of
the pregnancy, unless the person elects to have coverage
effective on the first day of the month following the date that
the person makes a plan selection."
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SECTION 21. A new section of the Health Maintenance
Organization Law is enacted to read:
"[NEW MATERIAL] COVERAGE FOR GENDER-AFFIRMING CARE.--
A. An individual or group health maintenance
organization contract delivered or issued for delivery in this
state shall provide coverage for gender-affirming care.
B. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
identity and the individual's sex assignment at birth.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
this state until an eligible enrollee's deductible has been
met."
SECTION 22. A new section of Nonprofit Health Care Plan
Law is enacted to read:
"[NEW MATERIAL] ABORTION CARE--NO COST SHARING.--
A. A health care plan delivered or issued for
delivery in this state shall provide coverage for the total
cost of abortion care.
B. The coverage shall not be subject to cost
sharing.
C. The provisions of this section shall not apply
to a high deductible health benefit plan issued or renewed in
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this state until an eligible insured's deductible has been
met."
SECTION 23. Section 59A-47-45.5 NMSA 1978 (being Laws
2019, Chapter 263, Section 9) is amended to read:
"59A-47-45.5. COVERAGE FOR CONTRACEPTION.--
A. A health care plan 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 form of
contraception in each of the contraceptive method categories
identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral
contraceptive pills to reflect the variety of oral
contraceptives approved by the federal food and drug
administration; [and]
(3) clinical services related to the provision
or use of contraception, including consultations, examinations,
procedures, ultrasound, anesthesia, patient education,
counseling, device insertion and removal, follow-up care and
side-effects management;
(4) a sufficient quantity to allow for the
continuous use of clinically appropriate contraception as
determined by the prescribing provider; and
(5) United States food and drug administation-
approved, -cleared or -granted over-the-counter contraception,
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including point-of-sale coverage for over-the counter
contraception at in-network dispensing entities without prior
authorization, step therapy, utilization management or cost
sharing.
B. Except as provided in Subsection C of this
section, the coverage required pursuant to this section shall
not be subject to:
(1) cost sharing for subscribers;
(2) utilization review;
(3) prior authorization or step-therapy
requirements; or
(4) any restrictions or delays on the
coverage, including quantity or fill limits if the practice
would result in a covered person receiving less than a
twelve-months' duration of contraception dispensed either at
one time or, if requested by the covered person at the point of
dispensing, over a twelve-month period .
C. A health care plan may discourage brand-name
pharmacy drugs or items by applying cost sharing to brand-name
drugs or items when at least one generic or therapeutic
equivalent is covered within the same method category of
contraception without cost sharing by the subscriber; provided
that when a subscriber's health care provider determines that a
particular drug or item is medically necessary, the health care
plan shall cover the brand-name pharmacy drug or item without
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cost sharing. A determination of medical necessity may include
considerations such as severity of side effects, differences in
permanence or reversibility of contraceptives and ability to
adhere to the appropriate use of the drug or item, as
determined by the attending provider.
D. A health care plan shall grant a subscriber an
expedited hearing to appeal any adverse determination made
relating to the provisions of this section. The process for
requesting an expedited hearing pursuant to this subsection
shall:
(1) be easily accessible, transparent,
sufficiently expedient and not unduly burdensome on a
subscriber, the subscriber's representative or the subscriber's
health care provider;
(2) defer to the determination of the
subscriber's health care provider; and
(3) provide for a determination of the claim
according to a time frame and in a manner that takes into
account the nature of the claim and the medical exigencies
involved for a claim involving an urgent health care need.
E. A health care plan shall not require a
prescription for any drug, item or service that is available
without a prescription.
F. A health care plan shall provide coverage and
shall reimburse a health care provider or dispensing entity on
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a per unit basis for dispensing [a six-month supply of
contraceptives] contraception intended to last the covered
person for a duration of twelve months, as permitted by the
covered person's prescription, dispensed at one time ; provided
that the contraceptives are prescribed and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to
prescribe [six] twelve months of contraceptives at one time;
[or]
(2) permit a health care plan to limit
coverage or impose cost sharing for an alternate method of
contraception if a subscriber changes contraceptive methods
before exhausting a previously dispensed supply;
(3) permit a plan or pharmacy benefits manager
to limit the quantity of contraceptives dispensed based on the
number of months left in the plan year; or
(4) permit a plan or pharmacy benefits manager
to deny coverage for the continuous use of clinically
appropriate contraception as determined by the prescribing
provider.
H. The provisions of this section shall not apply
to short-term travel, accident-only, hospital-indemnity-only,
limited-benefit or specified-disease health care plans.
I. The provisions of this section apply to health
care plans delivered or issued for delivery after January 1,
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2020.
J. For the purposes of this section:
(1) "contraceptive method categories
identified by the federal food and drug administration":
(a) means tubal ligation; sterilization
implant; copper intrauterine device; intrauterine device with
progestin; implantable rod; contraceptive shot or injection;
combined oral contraceptives; extended or continuous use oral
contraceptives; progestin-only oral contraceptives; patch;
vaginal ring; diaphragm with spermicide; sponge with
spermicide; cervical cap with spermicide; male and female
condoms; spermicide alone; vasectomy; ulipristal acetate;
levonorgestrel emergency contraception; and any additional
contraceptive method categories approved by the federal food
and drug administration; and
(b) does not mean a product that has
been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible,
copayment or coinsurance that a subscriber is required to pay
in accordance with the terms of a health care plan; and
(3) "health care provider" means an individual
licensed to provide health care in the ordinary course of
business.
K. A religious entity purchasing individual or
group health care plan coverage may elect to exclude
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prescription contraceptive drugs or items from the health
insurance coverage purchased."
SECTION 24. A new section of the Nonprofit Health Care
Plan Law is enacted to read:
"[NEW MATERIAL] SPECIAL ENROLLMENT PERIOD--PREGNANCY.--
A. A health care plan delivered or issued for
delivery in this state shall establish a special enrollment
period to provide coverage to an uninsured person when the
person provides a certification from a health care provider to
the insurer that the person is pregnant.
B. Coverage shall be effective before the end of
the first month in which the uninsured person receives
certification of the pregnancy, unless the person elects to
have coverage effective on the first day of the month following
the date that the person makes a plan selection."
SECTION 25. A new section of section of the Nonprofit
Health Care Plan Law is enacted to read:
"[NEW MATERIAL] COVERAGE FOR GENDER-AFFIRMING CARE.--
A. A health care plan delivered or issued for
delivery in this state shall provide coverage for gender-
affirming care.
B. As used in this section, "gender-affirming care"
means a procedure, service, drug, device or product that a
physical or behavioral health care provider prescribes to treat
an individual for incongruence between the individual's gender
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[bracketed material] = delete
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identity and the individual's sex assignment at birth.
C. The provisions of this section shall not apply
to a high deductible health benefit plans issued or renewed in
this state until an eligible subscriber's deductible has been
met."
SECTION 26. EFFECTIVE DATE.--The effective date of the
provisions of this act is January 1, 2026.
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