Health Care Benefits: New Mexico
Federal law and guidance on this subject should be reviewed together with this section.
Author: Patricia A. Morley, Research and Writing Associates, LLC
- New Mexico initially chose to establish a wholly state-based Marketplace under the Affordable Care Act, but then switched to a state-based, federally-supported Marketplace. See Health Insurance Marketplaces Under the ACA.
- New Mexico has taken steps to preserve certain benefits made available under the Affordable Care Act. See Preserving ACA Benefits.
- Same-sex marriage is legal nationwide. See Same-Sex Partner Benefits.
- Group health plans in New Mexico must include coverage for certain maternity and dependent benefits. See Maternity and Dependent Coverage.
- Health plans in New Mexico must provide or offer coverage for mental health and alcohol dependency treatments. Coverage for Autism Spectrum Disorders is required. See Mental Health and Alcohol Dependence Coverage.
- Group health plans must provide coverage for specified providers. See Specified Providers.
- Health plans that cover mastectomies must also cover minimum hospital stays. See Mastectomy and Minimum Hospital Stays.
- Health plans must provide, or offer, coverage for certain other illnesses, diseases, services, and medical and surgical procedures. See Coverage for Diabetes; Tobacco Cessation; Contraceptive Services; Home Health Care; Colorectal, Occult Breast and Cervical Cancer Screenings; Clinical Trials for Cancer; Orally Administered Anti-Cancer Medications.
- Certain coverage with regard to children and dependents is mandatory. See Coverage for Children and Dependents.
Health Insurance Marketplaces Under the ACA
The Affordable Care Act (ACA) required each state to establish its own Health Insurance Marketplace (or Exchange). New Mexico initially elected to establish a wholly state-based Marketplace, named Be Well New Mexico, but then switched to a state-based, federally-supported Marketplace.
Preserving ACA Benefits
New Mexico has taken steps to protect certain consumer protections and benefits available under the federal ACA by making sure they will remain available under New Mexico law regardless of the future of the ACA. +2019 Bill Text NM H.B. 436. Examples of such protections include:
- Providing stricter rules around premium ratings (+N.M. Stat. Ann. § 59A-18-13.1);
- Requiring certain small group health plans to provide coverage for essential health benefits (+N.M. Stat. Ann. § 59A-18-16.2(A));
- Prohibiting group health plans from establishing restricted lifetime or annual limits on the dollar value of essential health benefits (+N.M. Stat. Ann. § 59A-18-16.2(D));
- Requiring group health plans that provide certain benefits to provide coverage without cost-sharing requirements for specific preventive services (+N.M. Stat. Ann. § 59A-18-16.2(G));
- Prohibiting group health plans from imposing preexisting condition exclusions (+N.M. Stat. Ann. § 59A-23E-3);
- Prohibiting group health plans from imposing waiting periods that are longer than 90 days (+N.M. Stat. Ann. § 59A-23E-3);
- Prohibiting group health plans from discriminating based on the health status of individual participants and beneficiaries (+N.M. Stat. Ann. § 59A-23E-11);
- Prohibiting group health plans from discriminating based on health status against individual participants and beneficiaries in premium contributions (+N.M. Stat. Ann. § 59A-23E-12);
- Amending rules regarding guaranteed availability of coverage (+N.M. Stat. Ann. § 59A-23E-13); (+N.M. Stat. Ann. § 59A-23E-14); and
- Amending requirements related to coverage for mental health benefits (+N.M. Stat. Ann. § 59A-23E-18).
Same-Sex Partner Benefits
In 2013, same-sex marriage became legal in New Mexico. In 2015, the US Supreme Court ruled that, under the 14th Amendment, same-sex couples have a fundamental right to marry. See Obergefell v. Hodges, +2015 U.S. LEXIS 4250. Accordingly, same-sex marriage is legal nationwide. Therefore, employer health plans that offer spousal coverage should generally offer the same coverage to all spouses regardless of the sex of the spouses.
While federal law does not require an employer to offer health coverage to same-sex spouses, fully insured health plans are subject to state insurance laws. Accordingly, an employer that provides coverage for spouses through a fully insured plan will generally be required to provide such coverage equally for opposite-sex and same-sex spouses. Self-insured plans are not subject to state insurance laws and, therefore, may not be required to cover same-sex spouses. However, an employer with a self-insured plan that does not offer coverage to same-sex spouses as is offered to opposite-sex spouses may find an increased risk under federal and state nondiscrimination laws.
An employer that offers health care benefits to same-sex partners needs to ensure appropriate tax treatment for such benefits. See Taxation of Employee Benefits: New Mexico.
Maternity and Dependent Coverage
All group health insurance plans that provide maternity benefits must cover hospital stays of the mother and newly born child in accordance with federal law. Currently, that is at least 48 hours for a vaginal delivery and at least 96 hours for a delivery by caesarean section.
An employer's group health plan that provides maternity benefits must also cover medically necessary life-saving transportation, including air transit, for a high risk woman with an impending delivery. +N.M. Stat. Ann. § 59A-22-35.
An employer's group health plan must provide coverage for an alpha-fetoprotein screening test for pregnant women to screen for certain fetal genetic abnormalities.
Health plans that provide coverage for an insured's family members must provide coverage for newly-born children from the moment of birth and adoptive children from the time of placement. Coverage must include illness, injury and treatment for congenital illnesses and birth defects, when medically diagnosed. Transportation of the child, including air transit, to an appropriate treatment facility must also be covered. +N.M. Stat. Ann. § 59A-22-34; +N.M. Stat. Ann. § 59A-22-34.1.
Mental Health and Alcohol Dependence Coverage
Insurers must offer coverage for alcohol dependence treatment. If elected, the employer's group health plan must provide benefits subject to deductibles and coinsurance consistent with those of other benefits in the policy. Benefits must be available for no less than 30 days in a treatment center and 30 outpatient visits over a benefit period of one year. Lifetime maximums may be limited to two benefit periods. +N.M. Stat. Ann. § 59A-23-6.
An employer's group health plan must provide coverage for mental health benefits at terms no less favorable than for physical illnesses. More specifically, group health plans may not impose treatment limitations or financial restrictions, limitations or requirements on the provision of mental health benefits that are more restrictive than the predominant restrictions, limitations or requirements that are imposed on coverage of benefits for other conditions. +N.M. Stat. Ann. § 59A-23E-18. Substance abuse, chemical dependency and gambling addiction are specifically excluded from coverage.
However, group health plans may:
- Require pre-admission screening prior to the authorization of mental health benefits whether inpatient or outpatient; or
- Apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.
Group health plans are required to provide certain coverage for autism spectrum disorder diagnosis and treatment. +N.M. Stat. Ann. § 59A-23-7.9.
An employer's group health policy plan must generally include reimbursement for services provided by specified service providers. The specified service providers include, but are not limited to, optometrists, chiropractors, dentists, psychologists, podiatrists, acupuncturists, certified nurse midwives, registered lay midwives, registered nurses in expanded practice, osteopaths and physician assistants. +N.M. Stat. Ann. § 59A-22-32.
Mastectomy and Minimum Hospital Stays
An employer's group health plan must provide coverage for inpatient hospital stays of at least 48 hours following a mastectomy and at least 24 hours following a lymph node dissection for the treatment of breast cancer.
Absent specific state statutes, only large employers (those with 51 or more employees) must provide coverage for reconstructive breast surgery following a mastectomy in accordance with federal law.
Coverage for Diabetes
An employer's group health plan must provide coverage for medically necessary and prescribed equipment, supplies and self-management training and education including medical nutrition therapy, for the treatment of diabetes.
Equipment and supplies include:
- Blood glucose monitors including those with adaptations for the legally blind;
- Test strips for glucose monitors;
- Urine testing strips;
- Injection aids, lancets, lancet devices, syringes;
- Insulin pumps and all supplies for the pump;
- Insulin infusion devices;
- Prescribed oral agents for controlling blood sugars;
- 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
- Glucose agents, glucagon kits, insulin measurement and administration aids for the visually impaired.
An employer's group health plan that offers coverage for maternity benefits must also offer coverage for tobacco cessation coverage. +N.M. Stat. Ann. § 59A-22-44.
Group health plans that provide coverage for prescription benefits must also provide coverage for FDA approved prescription contraceptive drugs or devices. Coverage may be subject to deductibles and coinsurance consistent with other benefits. Religious entities may exclude this coverage. +N.M. Stat. Ann. § 59A-22-42.
Home Health Care
Insurers must offer the option of home health care coverage. If elected, the employer's group health plan must cover:
- Services provided by an RN or a LPN;
- Health Services of occupational, physical and respiratory therapists, home health aides and speech pathologists; and
- Medical supplies, drugs, medicines and laboratory services to the same extent they would have been covered for inpatient care.
Coverage must be for at least 100 home health care visits per insured per year with each visit including up to four hours of care. Services may be limited to those prescribed by a physician as long as it is renewed every 60 days, to those that if not provided would result in hospitalization of the insured and to those provided by a licensed home health agency. +N.M. Stat. Ann. § 59A-22-36.
Colorectal, Occult Breast and Cervical Cancer Screenings
Group health policies must make available screenings and pre-screenings for colorectal cancer when recommended by a health care provider in accordance with accepted professionally determined preventive guidelines. +N.M. Stat. Ann. § 59A-22-47; +N.M. Stat. Ann. § 59A-23-7.6.
Mammograms, to screen for occult breast cancer, must be covered by an employer's group health plan as follows:
- One baseline mammogram between the ages of 35-39;
- One mammogram every two years from 40-49; and
- An annual mammogram for women 50 and older.
An employer's group health plan must provide coverage for screening for cancerous and pre-cancerous cervical cancer as well as coverage for screening for the human papillomavirus (HPV). Cervical cancer screenings may consist of a Pap smear and pelvic examination for both symptomatic and asymptomatic women and are for women 18 and older based on the recommendation of a health care provider in accordance with professionally developed guidelines. HPV screening must be available every three years to women 30 and over. +N.M. Stat. Ann. § 59A-22-40.
Clinical Trials for Cancer
Group health plans must provide coverage for routine patient costs incurred during participation in clinical trial for cancer.
Patient costs include the cost of medically necessary treatment as a result of participation in the study. Costs do not include non-health care services the patient may require, costs associated with managing the research or the cost of the drug or device being investigated. +N.M. Stat. Ann. § 59A-22-43.
Orally Administered Anti-Cancer Medications
An employer's group health plan that provides coverage for cancer treatments must cover prescribed orally administered anti-cancer medications at terms no less favorable than those for intravenous or injected cancer medications that are covered as medical benefits. +N.M. Stat. Ann. § 59A-22-49.1; +N.M. Stat. Ann. § 59A-23-7-10.
Coverage for Children and Dependents
An employer's group health plan must provide certain coverage for children as follows:
- Well-child and well-baby care;
- Coverage for childhood immunizations, as well as necessary booster shots;
- One hearing aid per impaired ear every 36 months to age 18 or to age 21 if still in high school;
- Coverage of the HPV vaccine for females from age 9-14; and
- Medically necessary early intervention services from birth through three years of age up to $3,600 per year. This may not count toward maximum lifetime or annual limits.
No insurer's plan may deny coverage to a child based on the child's birth out of wedlock, the child not claimed on a parent's tax return or a child not residing with the parent. +N.M. Stat. Ann. § 59A-22-34.2.
A group health plan that provides coverage for dependents and contains a limiting age for coverage may not terminate a child who is physically or mentally disabled, incapable of self-sustaining employment and dependent on the insured for support. +N.M. Stat. Ann. § 59A-22-33.
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