SB0290

SENATE BILL 290

50th legislature - STATE OF NEW MEXICO - second session, 2012

INTRODUCED BY

Dede Feldman

AN ACT

RELATING TO HEALTH COVERAGE; AMENDING AND ENACTING SECTIONS OF THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO PROHIBIT LIFETIME OR ANNUAL LIMITS; PROVIDING FOR GUARANTEED ISSUE; BANNING PREEXISTING CONDITION EXCLUSIONS AND EXCESSIVE WAITING PERIODS; PROHIBITING RESCISSIONS OF COVERAGE EXCEPT IN CASES OF FRAUD OR INTENTIONAL MISREPRESENTATION OF MATERIAL FACT; MANDATING COVERAGE FOR INDIVIDUALS UNDER THE AGE OF TWENTY-SIX WHO SEEK COVERAGE UNDER THEIR PARENTS' COVERAGE; REQUIRING THAT INSURERS MAKE REBATES TO CONSUMERS WHEN ADMINISTRATIVE LOSSES EXCEED THE STATUTORY MAXIMUM; PROHIBITING LIFETIME OR ANNUAL LIMITS; PROVIDING FOR SMOKING AND TOBACCO CESSATION COVERAGE; ALIGNING COVERAGE FOR IMMUNIZATIONS, COLORECTAL CANCER SCREENINGS AND CYTOLOGIC AND HUMAN PAPILLOMAVIRUS SCREENINGS WITH FEDERAL GUIDELINES; PROVIDING FOR ALCOHOL DEPENDENCY AND MISUSE COVERAGE; PROHIBITING PREEXISTING CONDITION EXCLUSIONS FOR INDIVIDUALS UNDER THE AGE OF NINETEEN; PROHIBITING EMPLOYER-SPONSORED PLANS FROM DISCRIMINATING IN FAVOR OF HIGHLY COMPENSATED INDIVIDUALS; PROVIDING FOR APPLICABILITY TO "GRANDFATHERED" HEALTH PLAN COVERAGE; REQUIRING EMERGENCY SERVICES COVERAGE; PROVIDING FOR EXTENDED HEALTH COVERAGE FOR DISABLED CHILDREN; PROVIDING FOR OBSTETRICAL AND GYNECOLOGICAL PRIMARY CARE AND PEDIATRIC PRIMARY CARE; REQUIRING COVERAGE OF CERTAIN PREVENTIVE ITEMS AND SERVICES WITHOUT COST-SHARING; PROVIDING FOR RULEMAKING; AMENDING SECTIONS OF THE HEALTH CARE PURCHASING ACT AND THE MEDICAL CARE SAVINGS ACCOUNT ACT TO PROVIDE FOR DEPENDENT COVERAGE UNTIL THE AGE OF TWENTY-SIX; AMENDING A SECTION OF THE SMALL GROUP RATE AND RENEWABILITY ACT TO PROVIDE FOR RENEWABILITY OF COVERAGE, TO LIMIT ADJUSTED COMMUNITY RATING AND ADMINISTRATIVE LOSS RATIOS AND TO BAN PREEXISTING CONDITIONS EXCLUSIONS; PROVIDING FOR THE EXPULSION OR SUSPENSION OF FRATERNAL BENEFIT SOCIETY MEMBERSHIP FOR FRAUD OR INTENTIONAL MISREPRESENTATION OF MATERIAL FACT; PROVIDING FOR RESCISSION OR BREACH OF NONPROFIT HEALTH CARE PLAN SUBSCRIBER CONTRACTS IN CASES OF FRAUD OR INTENTIONALLY MISLEADING REPRESENTATIONS OF MATERIAL FACT; AMENDING THE HEALTH INSURANCE PORTABILITY ACT TO PROVIDE FOR RENEWABILITY OF COVERAGE; AMENDING A SECTION OF THE HEALTH INSURANCE ALLIANCE ACT TO REQUIRE GUARANTEED ISSUE AND RENEWABILITY AND SPECIAL ENROLLMENT; AMENDING SECTIONS OF THE PATIENT PROTECTION ACT TO EXTEND ITS PROVISIONS TO ALL HEALTH INSURANCE AND HEALTH CARE PLANS IN THE STATE; PROVIDING FOR INTERNAL GRIEVANCE PROCEDURES; PROVIDING FOR FORMAL HEARINGS ON VIOLATIONS OF THE PATIENT PROTECTION ACT.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1. Section 13-7-8 NMSA 1978 (being Laws 2003, Chapter 391, Section 2) is amended to read:

"13-7-8. MAXIMUM AGE OF [DEPENDENT] CHILD.--Any group health care coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act on or after July 1, 2003 that offers coverage of an insured's [dependent] child shall not terminate coverage of [an unmarried dependent] a child by reason of the [dependent's] child's age before the [dependent's twenty-fifth] child's twenty-sixth birthday [regardless of whether the dependent is enrolled in an educational institution]."

SECTION 2. Section 59A-18-13.1 NMSA 1978 (being Laws 1994, Chapter 75, Section 26, as amended) is amended to read:

"59A-18-13.1. ADJUSTED COMMUNITY RATING.--

A. Every insurer, fraternal benefit society, health maintenance organization or nonprofit health care plan that provides primary health insurance or health care coverage insuring or covering major medical expenses shall, in determining the initial year's premium charged for an individual, use only the rating factors of age, [gender pursuant to Subsection B of this section] geographic area of the place of employment and smoking practices, except that for individual policies the rating factor of the individual's place of residence may be used instead of the geographic area of the individual's place of employment.

B. In determining the initial and any subsequent year's rate, [the difference in rates in any one age group that may be charged on the basis of a person's gender shall not exceed another person's rates in the age group by more than the following percentage of the lower rate for policies issued or delivered in the respective year; provided, however, that gender shall not be used as a rating factor for policies issued or delivered on or after January 1, 2014:

(1) twenty percent for calendar year 2010;

(2) fifteen percent for calendar year 2011;

(3) ten percent for calendar year 2012; and

(4) five percent for calendar year 2013.

C.] no person's rate shall exceed the rate of any other person [with similar family composition] on the basis of age by more than two hundred fifty percent of the lower rate, except that the rates for children under the age of nineteen or children aged nineteen to twenty-five who are full-time students may be as much as three hundred percent lower than the [bottom] highest age-based rates [in the two hundred fifty percent band. The rating factor restrictions shall not prohibit an insurer, fraternal benefit society, health maintenance organization or nonprofit health care plan from offering rates that differ depending upon family composition].

C. No person's rate shall exceed the rate of any other person on the basis of geographic rating area by an amount that the superintendent shall establish by rule, after review by the United States department of health and human services.

D. The rate difference between any one person who smokes and any person who does not use tobacco shall not differ by more than one hundred fifty percent.

[D.] E. The provisions of this section do not preclude an insurer, fraternal benefit society, health maintenance organization or nonprofit health care plan from using health status or occupational or industry classification in establishing:

(1) rates for individual policies; or

(2) the amount an employer may be charged for coverage under the group health plan.

[E. As used in Subsection D of this section,

"health status" does not include genetic information.]

F. The superintendent shall adopt regulations to implement the provisions of this section."

SECTION 3. A new section of Chapter 59A, Article 18 NMSA 1978 is enacted to read:

"[NEW MATERIAL] UNIFORM HEALTH COVERAGE DOCUMENTS--STANDARDIZED DEFINITIONS.--

A. A health maintenance organization that offers an individual or group health care policy, plan, evidence of coverage or certificate of insurance in the state shall comply with the standards established by the superintendent by rule for the following documents issued by each policy, plan, evidence of coverage or certificate issued in the state relating to:

(1) a summary of benefits;

(2) an explanation of coverage;

(3) definitions of standard insurance terms and medical terms;

(4) exceptions, reductions and limitations on coverage;

(5) cost-sharing provisions, including deductible, coinsurance and copayment obligations;

(6) the renewability and continuation of coverage provisions;

(7) a coverage facts disclosure that includes examples that are based on nationally recognized clinical practice guidelines to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost-sharing;

(8) a statement that the health care plan:

(a) provides minimum essential coverage, as defined under Section 5000A(f) of the federal Internal Revenue Code of 1986; and

(b) ensures that the health care plan's share of the total allowed costs of benefits provided under the policy, plan, evidence of coverage or certificate is not less than sixty percent of those costs; and

(9) a contact number for the consumer to call with additional questions and an internet web address where a copy of the actual health care plan can be reviewed and obtained.

B. An insurer, health maintenance organization or nonprofit health care plan shall provide the following persons, prior to any enrollment restriction, a summary of benefits and coverage explanation required pursuant to Subsection A of this section:

(1) an applicant, at the time of application;

(2) an enrollee or subscriber, prior to the time of enrollment or re-enrollment, subscription or re-subscription; and

(3) a policyholder, plan holder, evidence of coverage holder, enrollee, subscriber or certificate holder, at the time of issuance of the policy, plan or evidence of coverage or the delivery of the certificate."

SECTION 4. Section 59A-22-2 NMSA 1978 (being Laws 1984, Chapter 127, Section 423) is amended to read:

"59A-22-2. FORM AND CONTENT OF POLICY.--

A. No policy of individual health insurance shall be delivered or issued for delivery in this state unless the policy sets forth:

(1) a summary of benefits;

(2) an explanation of coverage;

(3) definitions of standard insurance terms and medical terms;

(4) exceptions, reductions of indemnity and limitations on coverage;

(5) cost-sharing provisions, including deductible, coinsurance and copayment obligations;

(6) the renewability and continuation of coverage provisions;

(8) a statement of whether the policy:

(a) provides minimum essential coverage, as defined under Section 5000A(f) of the federal Internal Revenue Code of 1986; and

(b) ensures that the plan or coverage share of the total allowed costs of benefits provided under the policy is not less than sixty percent of those costs; and

(9) a contact number for the consumer to call with additional questions and an internet web address where a copy of the actual individual health coverage policy can be reviewed and obtained.

B. An insurer shall provide the following persons, prior to any enrollment restriction, a summary of benefits and coverage explanation required pursuant to Subsection A of this section:

(1) an applicant, at the time of application;

(2) an enrollee or subscriber, prior to the time of enrollment or re-enrollment, subscription or re-subscription; and

(3) a policyholder at the time of issuance of the policy.

C. No policy of individual health insurance shall be delivered or issued for delivery in this state unless: [A.] (1) the entire money and other considerations therefor are expressed therein; [and

B.] (2) the time at which insurance takes effect and terminates is expressed therein; [and

C.] (3) it purports to insure only one person, except as provided in Chapter 59A, Article 23 [of the Insurance Code] NMSA 1978, and except that a policy or contract may be issued upon application of the head of a family, who shall be deemed the policyholder, covering members of any one family, including husband, wife, [dependent] children [or any children] under the age of [nineteen (19)] twenty-six and [other] any dependents living with the family; [and

D.] (4) every printed portion of the text matter and of any endorsements or attached papers shall be printed in uniform type of which the face shall be not less than ten [(10)] point (the "text" shall include all printed matter except the name and address of the insurer, name and title of the policy, captions, subcaptions and form numbers), but notwithstanding any provision of this law, the superintendent shall not disapprove any such policy on the ground that every printed portion of its text matter or of any endorsement or attached paper is not printed in uniform type if it shall be shown that the type used is required to conform to the laws of another state in which the insurer is authorized; [and

E. the exceptions and reductions of indemnity are adequately captioned and clearly set forth in the policy or contract; and

F.] (5) each [such] form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and

[G.] (6) if any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of insurance laws of such other state shall have advised the superintendent that any such policy is not subject to approval or disapproval by such official, the superintendent may by ruling require that such policy meet the standards set forth in Sections [424 through 446 of this article] 59A-22-3 through 59A-22-25 NMSA 1978."

SECTION 5. Section 59A-22-5 NMSA 1978 (being Laws 1984, Chapter 127, Section 426, as amended) is amended to read:

"59A-22-5. TIME LIMIT ON CERTAIN DEFENSES.--

A. There shall be a provision for individual and group comprehensive major medical policies and plans as follows: As of the date of issue of this policy [no misstatements, except willful or fraudulent misstatements, made by the applicant in the application for this policy, shall be used to void the] or plan, a policy or [to deny] plan shall not be rescinded, nor shall a claim for loss incurred or disability [as defined in the policy] be denied, except when a covered individual:

(1) engages in conduct that constitutes fraud; or

(2) makes an intentional misrepresentation of material fact that is prohibited by the terms of the policy.

B. In the event [a misstatement in an application is made that is not fraudulent or willful] a misrepresentation of a material fact that is not intentional is made in an application, the issuer of the policy or plan may prospectively rate and collect from the insured the premium that would have been charged to the insured at the time the policy or plan was issued had [such misstatement] the misrepresentation not been made.

[B. There shall be a provision for policies other than comprehensive major medical policies as follows: After two years from the date of issue of this policy, no misstatements, except fraudulent misstatements, made by the applicant in the application for this policy shall be used to void the policy or to deny a claim for loss incurred or disability, as defined in the policy, commencing after the expiration of such two-year period.]

C. The foregoing policy and plan provisions shall not be so construed as to affect any initial two-year period nor to limit the application of Sections 59A-22-17 through 59A-22-19, 59A-22-21 and 59A-22-22 NMSA 1978 in the event of misstatement with respect to age or occupation or other insurance.

D. A policy or plan that the insured has the right to continue in force subject to its terms by the timely payment of premium [(1)] until at least age fifty or [(2)], in the case of a policy or plan issued after age forty-four, for at least five years from its date of issue, may contain in lieu of the foregoing the following provision, from which the clause in parentheses may be omitted at the insurance company's option, under the caption "Incontestable" [After this policy has been in force for a period of two years during the lifetime of the insured, excluding any period during which the insured is disabled, it shall become incontestable as to the statements contained in the application.

E. For individual policies that do not reimburse or pay as a result of hospitalization, medical or surgical expenses, no claim for loss incurred or disability (as defined in the policy) shall be reduced or denied on the ground that a disease or physical condition disclosed on the application and not excluded from coverage by name or a specific description effective on the date of loss had existed prior to the effective date of coverage of this policy. As an alternative, those policies may contain provisions under which coverage may be excluded for a period of six months following the effective date of coverage as to a given covered insured for a preexisting condition, provided that:

(1) the condition manifested itself within a period of six months prior to the effective date of coverage in a manner that would cause a reasonably prudent person to seek diagnosis, care or treatment; or

(2) medical advice or treatment relating to the condition was recommended or received within a period of six months prior to the effective date of coverage.

F. Individual policies that reimburse or pay as a result of hospitalization, medical or surgical expenses may contain provisions under which coverage is excluded during a period of six months following the effective date of coverage as to a given covered insured for a preexisting condition, provided that:

(2) medical advice or treatment relating to the condition was recommended or received within a period of six months prior to the effective date of coverage.

G. The preexisting condition exclusions authorized in Subsections E and F of this section shall be waived to the extent that similar conditions have been satisfied under any prior health insurance coverage if the application for new coverage is made not later than thirty-one days following the termination of prior coverage. In that case, the new coverage shall be effective from the date on which the prior coverage terminated.

H. Nothing in this section shall be construed to require the use of preexisting conditions or prohibit the use of preexisting conditions that are more favorable to the insured than those specified in this section]."

SECTION 6. Section 59A-22-6 NMSA 1978 (being Laws 1984, Chapter 127, Section 427) is amended to read:

"59A-22-6. GRACE PERIOD.--There shall be a provision as follows:

A grace period of........ (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.

[A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision, "Unless not less than five days prior to the premium due date the insurance company has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.".]"

SECTION 7. Section 59A-22-30.1 NMSA 1978 (being Laws 2005, Chapter 41, Section 1) is amended to read:

"59A-22-30.1. MAXIMUM AGE OF [DEPENDENT] CHILD.--An individual or group health plan, policy or certificate of insurance delivered, issued for delivery or renewed in New Mexico that provides coverage for an insured's [dependent] child shall not terminate coverage of [an unmarried dependent] a child by reason of the [dependent's] child's age before the [dependent's twenty-fifth] child's twenty-sixth birthday [regardless of whether the dependent is enrolled in an educational institution]."

SECTION 8. Section 59A-22-33 NMSA 1978 (being Laws 1984, Chapter 127, Section 455) is amended to read:

"59A-22-33. [HANDICAPPED] DISABLED CHILDREN--COVERAGE CONTINUED.--

A. An individual or group hospital or medical expense insurance policy or plan delivered or issued for delivery in this state [which] that provides that coverage of a [dependent] child of an insured, or of an employee or other member of the covered group, shall terminate upon attainment of the limiting age for [dependent] children specified in the policy or plan shall also provide, in substance, that attainment of the limiting age shall not operate to terminate the coverage of a child while the child is, and continues to be, both incapable of self-sustaining employment, by reason of [mental retardation] cognitive or physical [handicap] disability, and chiefly dependent upon the policyholder or plan holder for support and maintenance. However, proof of the incapacity and dependency of the child must be furnished to the insurer by the insured employee or member within thirty-one [(31)] days of the child's attainment of the limiting age and subsequently, as may be required by the insurer, but not more frequently than annually after the two-year period following the child's attainment of the limiting age.

B. No limiting age shall be set before age twenty-six."

SECTION 9. Section 59A-22-34.2 NMSA 1978 (being Laws 1994, Chapter 64, Section 2, as amended) is amended to read:

"59A-22-34.2. COVERAGE OF CHILDREN.--

A. An insurer shall not deny enrollment of a child under the health plan or policy of the child's parent on the grounds that the child:

(1) was born out of wedlock;

(2) is not claimed as a dependent on the parent's federal tax return; or

(3) does not reside with the parent or in the insurer's service area.

B. When a child has health coverage through an insurer of a noncustodial parent, the insurer shall:

(1) provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;

(2) permit the custodial parent or the provider, with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent; and

(3) make payments on claims submitted in accordance with Paragraph (2) of this subsection directly to the custodial parent, the provider or the state medicaid agency.

C. When a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage, the insurer shall be required:

(1) to permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;

(2) if the parent is enrolled but fails to make application to obtain coverage for the child, to enroll the child under family coverage upon application of the child's other parent, the state agency administering the medicaid program or the state agency administering 42 U.S.C. Sections 651 through 669, the child support enforcement program; and

(3) not to disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:

(a) the court or administrative order is no longer in effect; or

(b) the child is or will be enrolled in comparable health coverage through another insurer that will take effect not later than the effective date of disenrollment.

D. An insurer shall not impose requirements on a state agency that has been assigned the rights of an individual eligible for medical assistance under the medicaid program and covered for health benefits from the insurer that are different from requirements applicable to an agent or assignee of any other individual so covered.

E. An insurer shall provide coverage for children, from birth through three years of age, for or under the family, infant, toddler program administered by the department of health, provided that eligibility criteria are met [for a maximum benefit of three thousand five hundred dollars ($3,500) annually] for medically necessary early intervention services provided as part of an individualized family service plan and delivered by certified and licensed personnel as defined in 7.30.8 NMAC who are working in early intervention programs approved by the department of health. [No payment under this subsection shall be applied against any maximum lifetime or annual limits specified in the policy, health benefits plan or contract.]"

SECTION 10. A new section of Chapter 59A, Article 22 NMSA 1978, is enacted to read:

"[NEW MATERIAL] ALCOHOL DEPENDENCY AND MISUSE COVERAGE.--

A. Each insurer that delivers or issues for delivery in this state a group health insurance policy shall offer and make available benefits for the necessary care and treatment of alcohol dependency and misuse. These benefits shall provide necessary care and treatment in an alcohol dependency and misuse treatment center and outpatient visits for alcohol dependency and misuse treatment.

B. For purposes of this section, "alcohol dependency and misuse treatment center" means a facility that provides a program for the treatment of alcohol dependency and misuse pursuant to a written treatment plan approved and monitored by a physician or meeting the quality standards of the behavioral health services division of the human services department and which facility also:

(1) is affiliated with a hospital under a contractual agreement with an established system for patient referral;

(2) is accredited as such a facility by the joint commission; or

(3) meets at least the minimum standards adopted by the behavioral health services division for treatment of alcohol dependency and misuse in regional treatment centers.

C. This section applies to policies delivered or issued for delivery or renewed, extended or amended in this state on or after July 1, 1983 or upon expiration of a collective bargaining agreement applicable to a particular policyholder, whichever is later; provided that this section does not apply to blanket, short-term travel, accident-only, limited or specified disease or individual conversion policies or policies designed for issuance to persons eligible for coverage under Title 18 of the federal Social Security Act, known as medicare, or any other similar coverage under state or federal governmental plans. With respect to any policy forms approved by the insurance division of the commission prior to the effective date of this section, an insurer is authorized to comply with this section by the use of endorsements or riders; provided that such endorsements or riders are approved by the insurance division as being in compliance with this section and applicable provisions of the Insurance Code.

D. If an organization offering group health benefits to its members makes more than one health insurance policy or nonprofit health care plan available to its members on a member option basis, the organization shall not require alcohol dependency and misuse coverage from one health insurer or health care plan without requiring the same level of alcohol dependency and misuse coverage for all other health insurance policies or health care plans that the organization makes available to its members."

SECTION 11. Section 59A-22-34.3 NMSA 1978 (being Laws 1997, Chapter 250, Section 1) is amended to read:

"59A-22-34.3. CHILDHOOD IMMUNIZATION COVERAGE REQUIRED.--

A. Each individual and group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in this state shall provide coverage for childhood immunizations, as well as coverage for medically necessary booster doses of all immunizing agents used in child immunizations, in accordance with the current schedule of immunizations recommended by the American academy of pediatrics or the advisory committee on immunization practices of the federal centers for disease control and prevention, whichever provides greater coverage.

B. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified disease policies.

[C. Coverage for childhood immunizations and necessary booster doses may be subject to deductibles and co-insurance consistent with those imposed on other benefits under the same policy, plan or certificate.]"

SECTION 12. Section 59A-22-40 NMSA 1978 (being Laws 1992, Chapter 56, Section 2, as amended) is amended to read:

"59A-22-40. COVERAGE FOR CYTOLOGIC AND HUMAN PAPILLOMAVIRUS SCREENING.--

A. Each individual and group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in this state shall provide coverage for cytologic and human papillomavirus screening for determining the presence of precancerous or cancerous conditions and other health problems. The coverage shall make available cytologic screening, as determined by the health care provider in accordance with national medical standards and United States preventive services task force "A"-rated and "B"-rated recommendations, whichever provides greater coverage, for women who are eighteen years of age or older and for women who are at risk of cancer or at risk of other health conditions that can be identified through cytologic screening. The coverage shall make available human papillomavirus screening once every three years for women aged thirty and older.

B. Coverage for cytologic and human papillomavirus screening may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.

C. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified-disease policies.

D. For the purposes of this section:

(1) "cytologic screening" means a Papanicolaou test and a pelvic exam for asymptomatic as well as symptomatic women;

(2) "health care provider" means any person licensed within the scope of [his] the person's practice to perform cytologic and human papillomavirus screening, including physicians, physician assistants, certified nurse-midwives and certified nurse practitioners; and

(3) "human papillomavirus screening" means a test approved by the federal food and drug administration for detection of the human papillomavirus."

SECTION 13. Section 59A-22-44 NMSA 1978 (being Laws 2003, Chapter 337, Section 1) is amended to read:

"59A-22-44. COVERAGE FOR SMOKING CESSATION TREATMENT.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state and that offers maternity benefits shall offer coverage for smoking cessation treatment and shall offer augmented counseling tailored to pregnant women who smoke.

[B. Coverage for smoking cessation treatment may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.]

B. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state shall:

(1) offer tobacco cessation intervention coverage for those who use tobacco products;

(2) provide for screening of pregnant women for tobacco use in accordance with the United States preventive services task force guidelines; and

(3) provide diagnostic, therapy and counseling services and pharmacotherapy, including the coverage of prescription and nonprescription tobacco cessation agents approved by the federal food and drug administration for cessation of tobacco use by pregnant women.

C. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified-disease policies."

SECTION 14. Section 59A-22-47 NMSA 1978 (being Laws 2007, Chapter 17, Section 1) is amended to read:

"59A-22-47. COVERAGE OF COLORECTAL CANCER SCREENING.--

A. An individual or group health insurance policy, health care plan and certificate of health insurance that is delivered, issued for delivery or renewed in this state shall provide coverage for colorectal screening for determining the presence of precancerous or cancerous conditions and other health problems. The coverage shall make available colorectal cancer screening, as determined by the health care provider in accordance with [the evidence-based recommendations established by] practices that have, in effect, a rating of "A" or "B" in the current recommendations of the United States preventive services task force.

[B. Coverage for colorectal screening may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.

C.] B. The provisions of this section shall not apply to short-term travel, accident-only or limited or specified-disease policies or plans."

SECTION 15. Section 59A-22-49 NMSA 1978 (being Laws 2009, Chapter 74, Section 1) is amended to read:

"59A-22-49. COVERAGE FOR AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--

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 to an eligible individual who is nineteen years of age or younger or an eligible individual who is twenty-two years of age or younger and is enrolled in high school for:

(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and

(2) treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

[(2) shall be limited to thirty-six thousand dollars ($36,000) annually and shall not exceed two hundred thousand dollars ($200,000) in total lifetime benefits.

Beginning January 1, 2011, the maximum benefit shall be adjusted annually on January 1 to reflect any change from the previous year in the medical component of the then-current consumer price index for all urban consumers published by the bureau of labor statistics of the United States department of labor;

(3)] (2) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

[(4)] (3) may be subject to other general exclusions and limitations of the insurer's policy or plan, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and

[(5)] (4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three to twenty-two years of age who have autism spectrum disorder.

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health insurance policy, health care plan or certificate of health insurance, except as otherwise provided in Subsection B of this section.

D. An insurer shall not deny or refuse to issue health insurance coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health insurance coverage for an individual because the individual is diagnosed as having autism spectrum disorder.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance policy or plan to pay claims appropriately. These elements include, but are not limited to:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health insurance policy or plan.

G. The provisions of this section shall not apply to policies or plans intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity, other limited-benefit health insurance policies or plans.

H. As used in this section:

(1) "autism spectrum disorder" means a condition that meets the diagnostic criteria for the pervasive developmental disorders published in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, also known as DSM-IV-TR, published by the American psychiatric association, including autistic disorder; Asperger's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder;

(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain and restore to the maximum extent practicable the functioning of an individual; and

(3) "high school" means a school providing instruction for any of the grades nine through twelve."

SECTION 16. Section 59A-22-50 NMSA 1978 (being Laws 2010, Chapter 94, Section 1) is amended to read:

"59A-22-50. HEALTH INSURERS--DIRECT SERVICES.--

A. A health insurer shall make reimbursement for direct services at a level not less than eighty-five percent of premiums across all health product lines, except individually underwritten health insurance policies, contracts or plans, that are governed by the provisions of Chapter 59A, Article 22 NMSA 1978, the Health Maintenance Organization Law and the Nonprofit Health Care Plan Law. Reimbursement shall be made for direct services provided over the preceding three calendar years, but not earlier than calendar year 2010, as determined by reports filed with the insurance division of the commission. Nothing in this subsection shall be construed to preclude a purchaser from negotiating an agreement with a health insurer that requires a higher amount of premiums paid to be used for reimbursement for direct services for one or more products or for one or more years.

B. For individually underwritten health care policies, plans or contracts, the superintendent shall establish, after notice and informal hearing, the level of reimbursement for direct services, as determined by the reports filed with the insurance division, as a percent of premiums. Additional informal hearings may be held at the superintendent's discretion. In establishing the level of reimbursement for direct services, the superintendent shall consider the costs associated with the individual marketing and medical underwriting of these policies, plans or contracts at a level not less than seventy-five percent of premiums. A health insurer writing these policies, plans or contracts shall make reimbursement for direct services at a level not less than that level established by the superintendent pursuant to this subsection over the three calendar years preceding the date upon which that rate is established, but not earlier than calendar year 2010. Nothing in this subsection shall be construed to preclude a purchaser of one of these policies, plans or contracts from negotiating an agreement with a health insurer that requires a higher amount of premiums paid to be used for reimbursement for direct services.

C. An insurer that fails to comply with the reimbursement requirements pursuant to this section shall issue a [dividend or credit against future premiums] rebate to all policyholders or plan holders in [an amount sufficient to assure that the benefits paid in the preceding three calendar years plus the amount of the dividends or credits are equal to the required direct services reimbursement level pursuant to Subsection A of this section for group health coverage and blanket health coverage or the required direct services reimbursement level pursuant to Subsection B of this section for individually underwritten health policies, contracts or plans for the preceding three calendar years] accordance with rules that the superintendent has promulgated. If the insurer fails to issue the [dividend or credit] rebate in accordance with the requirements of this section, the superintendent shall enforce these requirements and may pursue any other penalties as provided by law, including general penalties pursuant to Section 59A-1-18 NMSA 1978.

D. After notice and hearing, the superintendent [may] shall adopt and promulgate reasonable rules necessary and proper to carry out the provisions of this section.

E. For the purposes of this section:

(1) "direct services" means services rendered to an individual by a health insurer or a health care practitioner, facility or other provider, including case management, disease management, health education and promotion, preventive services, quality incentive payments to providers and any portion of an assessment that covers services rather than administration and for which an insurer does not receive a tax credit pursuant to the Medical Insurance Pool Act or the Health Insurance Alliance Act; provided, however, that "direct services" does not include care coordination, utilization review or management or any other activity designed to manage utilization or services;

(2) "health insurer" means a person duly authorized to transact the business of health insurance in the state pursuant to the Insurance Code but does not include a person that only issues a limited-benefit policy intended to supplement major medical coverage, including medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income; and

(3) "premium" means all income received from individuals and private and public payers or sources for the procurement of health coverage, including capitated payments, self-funded administrative fees, self-funded claim reimbursements, recoveries from third parties or other insurers and interests less any premium tax paid pursuant to Section 59A-6-2 NMSA 1978 and fees associated with participating in a health insurance exchange that serves as a clearinghouse for insurance."

SECTION 17. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] CHILD DEFINED.--As used in Chapter 59A, Article 22 NMSA 1978, "child" means an individual under twenty-six years of age whom the principal insured covers or whom the applicant for coverage applies to cover, regardless of the individual's financial dependency, residency with a parent, student status, employment and marital status."

SECTION 18. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] GRANDFATHERED HEALTH PLAN OR GRANDFATHERED HEALTH POLICY COVERAGE.--

A. For the purposes of Chapter 59A, Article 22 NMSA 1978, "grandfathered health plan" or "grandfathered health policy coverage" means individual coverage provided by a health insurer, health maintenance organization or nonprofit health plan that was in effect on March 23, 2010 and that remains in effect through the original term of coverage or through renewal of the original term.

B. A dependent of an individual enrolled in a grandfathered health plan may enroll in a grandfathered health plan or policy if the terms of the plan in effect as of March 23, 2010 permitted the dependent to enroll.

C. A group health plan that provides coverage on March 23, 2010 may provide for the enrolling of new employees and their dependents in that grandfathered health plan.

D. Coverage provided by a health insurer, health maintenance organization or nonprofit health plan pursuant to one or more collective bargaining agreements between employee representatives and one or more employers that was ratified before March 23, 2010 constitutes a grandfathered health plan until the date on which the last of the collective bargaining agreements relating to the coverage terminates. Any coverage amendment made pursuant to a collective bargaining agreement that relates to the coverage and amends the coverage solely to conform to any requirement of Chapter 59A, Article 22 NMSA 1978 shall not be treated as a termination of the collective bargaining agreement."

SECTION 19. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] GUARANTEED ISSUE--GUARANTEED RENEWABILITY--MAXIMUM WAITING PERIOD--BAN ON PREEXISTING CONDITION EXCLUSIONS.--

A. A health insurer shall issue coverage to any individual who requests and offers to purchase the coverage without permanent exclusion of preexisting conditions.

B. A health insurer shall renew any policy or plan at the individual's option, except as provided pursuant to rules that the superintendent has promulgated.

C. A health insurer may impose a waiting period not to exceed ninety days before payment for any service related to a preexisting condition.

D. A health insurer shall offer or make a referral to a transition product to provide coverage during the waiting period due to a preexisting condition.

E. A health insurer may continue and renew a grandfathered plan or policy that has a permanent exclusion of payment for preexisting conditions.

F. A health insurer may restrict enrollment in coverage described in Subsection A of this section to open or special enrollment periods; provided that any special enrollment period shall comply with the provisions of Section 21 of this 2012 act and rules the superintendent has promulgated.

G. For the purposes of this section:

(1) "coverage" means a health insurance policy, health care plan, health maintenance organization contract or certificate of insurance issued for delivery in the state. "Coverage" does not mean a short-term, accident, fixed indemnity or specified disease policy; disability income; limited benefit insurance; credit insurance; workers' compensation; or automobile or medical insurance under which benefits are payable with or without regard to fault and that is required by law to be contained in any liability insurance policy; and

(2) "preexisting condition" means a physical or mental condition for which medical advice, medication, diagnosis, care or treatment was recommended for or received by an applicant for health insurance within six months before the effective date of coverage, except that pregnancy is not considered a preexisting condition for federally defined individuals."

SECTION 20. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PROHIBITION ON LIFETIME OR ANNUAL LIMITS.--

A. Notwithstanding any other provision of law, a group health plan, health insurance issuer offering group or individual health insurance coverage, health maintenance organization, fraternal benefit society or nonprofit organization shall not establish:

(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or

(2) except as provided in Subsection B of this section, annual limits on the dollar value of benefits for any participant or beneficiary.

B. With respect to plan years beginning prior to January 1, 2014, a group health plan, health insurance issuer offering group or individual health insurance coverage, health maintenance organization, fraternal benefit society or nonprofit organization shall establish a restricted annual limit on the dollar value of benefits for any participant or beneficiary only with respect to the scope of benefits that are essential health benefits, as the superintendent defines "essential health benefits" by rule.

C. Subsection A of this section shall not be construed to prevent a group health plan, health insurance issuer offering group or individual health insurance coverage, health maintenance organization, fraternal benefit society or nonprofit organization from placing annual or lifetime per beneficiary limits on specific covered benefits that are not essential health benefits to the extent that these limits are otherwise permitted under federal or state law.

D. The provisions of this section shall not apply to policies or plans intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policies or plans."

SECTION 21. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] INDIVIDUALS WHOSE COVERAGE ENDED BY REASONS OF CESSATION OF DEPENDENT STATUS--APPLICABILITY--OPPORTUNITY TO ENROLL--WRITTEN NOTICE.--

A. For plan or policy years beginning on or after September 23, 2010, if a child's coverage ended or did not begin for the reasons described in Subsection E of this section, a health insurer shall provide the child an opportunity to enroll in a health plan or policy for which coverage continues for at least sixty days and provide written notice of the opportunity to enroll as described in Subsection B of this section no later than the first day of the plan or policy year.

C. For an individual who enrolls in an individual health insurance policy or health plan, the coverage shall take effect not later than the first day of the first plan or policy year.

D. A child enrolling pursuant to this section in a group health insurance policy or health plan shall be considered a "special enrollee" pursuant to Section 59A-23E-8 NMSA 1978. The child and the principal insured shall be offered all of the benefit packages available to similarly situated individuals who were denied coverage or whose coverage ended by reason of cessation of dependent status. Any difference in benefits or cost-sharing requirements constitutes a different benefit package. The child shall not be required to pay more for coverage than similarly situated individuals who did not lose coverage by reason of cessation of dependent status.

E. The provisions of this section shall apply to a child:

(1) whose coverage ended, or who was denied coverage or was not eligible for coverage under an individual or a group health insurance policy or health plan because, under the terms of coverage, the availability of dependent coverage of a child ended before the child reached the age of twenty-six; or

(2) who became eligible, or is required to become eligible, for coverage on the first day of the first plan or policy year, beginning on or after September 23, 2010 by reason of the provisions of this section."

SECTION 22. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] GRANDFATHERED HEALTH PLANS--ADULT CHILD DEPENDENT ELIGIBLE FOR EMPLOYER-SPONSORED HEALTH BENEFIT PLAN--EXCLUSION FROM DEPENDENT COVERAGE ELIGIBILITY PERMITTED.--

A. For plan years beginning before January 1, 2014, a group health plan providing group health insurance coverage that is a grandfathered health plan and makes available dependent coverage of children may exclude an adult child under twenty-six years of age from coverage only if the adult child is eligible to enroll in an eligible employer-sponsored health benefit plan, as defined in Section 5000A(f)(2) of the federal Internal Revenue Code of 1986, other than the group health plan of a parent.

B. For the purposes of this section "adult child" means an individual eighteen to twenty-six years of age."

SECTION 23. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PROHIBITION ON PREEXISTING CONDITION EXCLUSIONS FOR INDIVIDUALS UNDER THE AGE OF NINETEEN.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state shall not limit or exclude coverage under an individual or group health benefit plan for an individual under the age of nineteen by imposing a preexisting condition exclusion on that individual.

B. When a health insurer offers individual or group health insurance coverage that only covers individuals under age nineteen, that insurer shall offer the coverage continuously throughout the year or during one or more open enrollment periods as the superintendent prescribes by rule.

C. During an open enrollment period, a health insurer shall not deny or unreasonably delay the issuance of a policy, plan or certificate, refuse to issue a policy, plan or certificate or issue a policy, plan or certificate with any preexisting condition exclusion rider or endorsement to an applicant or insured who is under the age of nineteen on the basis of a preexisting condition.

D. Coverage shall be effective for those applying during an open enrollment period on the same basis as any applicant qualifying for coverage on an underwritten basis.

E. Each health insurer shall provide prior prominent public notice on its web site and written notice to each of its policyholders or plan holders annually at least ninety days before any open enrollment period of the open enrollment rights for individuals under the age of nineteen and shall provide information as to how an individual eligible for this open enrollment right may apply for coverage with the insurer during an open enrollment period."

SECTION 24. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] EMERGENCY SERVICES.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state and that provides or covers any benefits with respect to services in an emergency department of a hospital shall cover emergency services:

(1) without the need for any prior authorization determination; and

(2) whether or not the health care provider furnishing emergency services is a participating provider with respect to emergency services.

B. If emergency services are provided to a covered individual by a nonparticipating health care provider with or without prior authorization, the services shall be provided without imposing any requirement under the policy, plan or certificate for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the insurer for the provision of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the health insurer.

C. If emergency services are provided out of network, the cost-sharing requirement, expressed as a copayment amount or coinsurance rate, shall be the same requirement that would apply if the emergency services were provided in-network and without regard to any other term or condition of such coverage, other than exclusion or coordination of benefits, or an affiliation or waiting period other than the applicable cost-sharing otherwise permitted pursuant to state or federal law.

D. The provisions of this section shall not apply to:

(1) policies or plans intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policies or plans; or

(2) health insurance policies, plans, certificates or subscriber agreements that are governed by the provisions of Section 59A-22A-5 NMSA 1978.

E. As used in this section:

(1) "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in one of the following conditions:

(a) placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

(b) serious impairment to bodily functions; or

(2) "emergency services" means, with respect to an emergency medical condition:

(a) a medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and

(b) according to the capabilities of the staff and facilities available at the hospital, further medical examination and treatment required to stabilize the patient's emergency medical condition or safe transfer of the patient to another medical facility capable of providing the medical examination or treatment required to stabilize the patient's emergency medical condition; and

(3) "stabilize" means:

(a) to provide medical treatment of an emergency medical condition as necessary to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility; or

(b) with respect to a pregnant woman who is having contractions, to deliver, including a placenta."

SECTION 25. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] OPTION FOR PEDIATRICIAN AS PRIMARY CARE PHYSICIAN.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state that requires or provides for the designation of a participating primary care provider shall allow a principal insured to designate for the principal insured's dependent child who is a covered individual an allopathic or osteopathic physician who specializes in pediatrics as the principal insured child's primary care provider if the provider participates in the network of the plan or issuer.

B. Nothing in Subsection A of this section shall be construed to waive any exclusions of coverage under the terms and conditions of the plan or health insurance policy with respect to coverage of pediatric care.

C. As used in this section, "primary care provider" means a health care practitioner acting within the scope of the health care practitioner's license who provides the first level of basic or general health care for a covered individual's health needs, including diagnostic and treatment services, who initiates referrals to other health care practitioners and who maintains the continuity of care when appropriate."

SECTION 26. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] OBSTETRICAL AND GYNECOLOGICAL PRIMARY CARE OPTION.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state that provides coverage for obstetrical and gynecological care and that requires that covered individuals designate a primary care provider shall not require authorization or referral by the plan or issuer or any person, including a primary care provider, when a female covered individual seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. The obstetrical or gynecological health care provider shall agree otherwise to adhere to the plan's or issuer's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing services pursuant to a treatment plan approved by the plan or issuer.

B. A health insurer shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services by a participating health care professional who specializes in obstetrics or gynecology, as the authorization of the primary care provider.

C. Nothing in Subsection A of this section shall be construed to:

(1) waive any exclusions of coverage under the terms and conditions of the plan or health insurance policy with respect to coverage of obstetrical or gynecological care; or

(2) preclude the health insurer from requiring that the obstetrical or gynecological provider notify the covered individual's primary care health care professional or the plan or issuer of treatment decisions.

D. As used in this section, "primary care provider" means a health care practitioner acting within the scope of the health care practitioner's license who provides the first level of basic or general health care for a person's health needs, including diagnostic and treatment services, who initiates referrals to other health care practitioners and who maintains the continuity of care when appropriate."

SECTION 27. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PREVENTIVE ITEMS AND SERVICES--PROHIBITION ON COST-SHARING.--

A. A health insurer providing coverage under an individual health benefit policy or plan, except for a grandfathered health policy or plan, shall provide coverage for items and services pursuant to Sections 59A-22-34.3, 59A-22-40, 59A-22-44 and 59A-22-47 NMSA 1978 and Sections 28 through 30 of this 2012 act and shall not impose any cost-sharing requirements, such as a copayment, coinsurance or deductible. B. A health insurer is not required to provide coverage for any items or services specified in any recommendation or guideline described in Subsection A of this section after the recommendation or guideline is no longer described by a source listed in that subsection.

C. Other provisions of state or federal law may apply in connection with a health insurer's ceasing to provide coverage for any such items or services.

D. To the extent that a preventive care provision in this section conflicts with any other preventive health care law in New Mexico, the provision providing the greatest level of coverage shall apply. The preventive care provisions in this section are intended to supplement rather than supplant existing preventive health care provisions in this state.

E. The superintendent shall at least annually revise the preventive services standards established pursuant to Sections 59A-22-44 and 59A-22-47 NMSA 1978 and Sections 28 through 30 of this 2012 act to ensure that they are respectively consistent with the current "A"-rated and "B"-rated recommendations of the United States preventive services task force, the advisory committee on immunization practices of the federal centers for disease control and prevention and the guidelines with respect to infants, children, adolescents and women of evidence-based preventive care and screenings by the federal health resources and services administration. When changes are made to any of these guidelines or recommendations, the superintendent shall make recommendations to the legislature for legislative changes to conform these standards to current guidelines and recommendations.

F. An insurer may impose cost-sharing requirements with respect to an office visit if a preventive item or service provided pursuant to this section is billed separately or is tracked as individual encounter data separately from the office visit.

G. An insurer shall not impose cost-sharing requirements with respect to an office visit for an item or service provided pursuant to this section if an item or service is not billed separately or is not tracked as individual encounter data separately from the office visit and the primary purpose of the office visit is the delivery of the preventive item or service.

H. An insurer may impose cost-sharing requirements with respect to an office visit if a preventive item or service provided pursuant to this section is not billed separately or is not tracked as individual encounter data separately from the office visit and the primary purpose of the office visit is not the delivery of the preventive item or service.

I. The provisions of this section shall not apply to policies or plans intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policies or plans."

SECTION 28. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PREVENTIVE SERVICES BENEFITS--ASPIRIN REGIMEN--HIGH BLOOD PRESSURE SCREENING--BREAST CANCER SCREENING--LIPID DISORDERS SCREENING--COLORECTAL CANCER SCREENING--DEPRESSION SCREENING--BEHAVIORAL DIETARY COUNSELING--OBESITY COUNSELING AND SCREENING--OSTEOPOROSIS SCREENING.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in this state shall provide the following benefits that have, in effect, a rating of "A" or "B" in the current recommendations of the United States preventive services task force, for:

(1) a one-time screening for abdominal aortic aneurysm by ultrasonography in men who have ever smoked and who are between the ages of sixty-five and seventy-five;

(2) an aspirin regimen for men between the ages of forty-five and seventy-nine when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage;

(3) an aspirin regimen for women between the ages of fifty-five and seventy-nine when the potential benefit of a reduction in ischemic strokes outweighs the potential harm due to an increase in gastrointestinal hemorrhage;

(4) screening for high blood pressure in adults aged eighteen and older;

(5) genetic counseling and evaluation for breast cancer BRCA-gene testing for women whose family histories are associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes. Nothing in this section shall be construed as a waiver or exception to the Genetic Information Privacy Act;

(6) screening of lipid disorders for:

(a) men who are thirty-five years of age or older; and

(b) women who are twenty years of age or older who are at increased risk of coronary heart disease;

(7) screening of individuals over eighteen years of age for colorectal cancer using fecal occult blood testing, sigmoidoscopy or colonoscopy;

(8) screening of individuals eighteen years of age or older for depression;

(9) screening of individuals twelve to eighteen years of age for major depressive disorder;

(10) behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease;

(11) screening and counseling for obesity for:

(a) individuals eighteen years of age and older who are obese; and

(b) individuals six to eighteen years of age; and

(12) screening for osteoporosis for:

(a) women who are sixty-five years of age and older; and

(b) women who are sixty to sixty-five years of age who are at increased risk for osteoporotic fractures.

B. The provisions of this section shall not apply to policies or plans intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or other limited-benefit health insurance policies or plans."

SECTION 29. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PREVENTIVE SERVICES FOR CHILDREN.--

(1) oral fluoride supplementation at currently recommended doses to children six months of age to five years of age whose primary water sources are deficient in fluoride;

(2) prophylactic ocular topical medication against gonococcal ophthalmia neonatorum for newborns;

(3) screening for hearing loss in newborns;

(4) screening for sickle cell disease for newborns;

(5) screening for congenital hypothyroidism for newborns;

(6) iron supplementation for asymptomatic children six to twelve months of age who are at increased risk for iron deficiency anemia;

(7) screening for phenylketonuria in newborns; and

(8) screening to detect amblyopia, strabismus and defects in visual acuity in children less than five years of age.

SECTION 30. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PREVENTIVE SERVICES FOR PREGNANT WOMEN-- REPRODUCTIVE HEALTH.--

(1) screening for asymptomatic bacteriuria with a urine culture for pregnant women;

(2) interventions during pregnancy and after birth to promote and support breastfeeding;

(3) screening for cervical cancer in women who have been sexually active and have a cervix;

(4) screening for chlamydial infection for:

(a) all sexually active young women twenty-four years of age and younger; and

(b) older women who are at increased risk of chlamydial infection;

(5) a daily supplement containing four hundred to eight hundred micrograms of folic acid for any woman planning a pregnancy or capable of pregnancy;

(6) screening of all sexually active women who are at increased risk for infection, including those who are pregnant, for gonorrheal infection;

(7) screening for iron deficiency anemia in asymptomatic pregnant women;

(8) Rh (D) blood typing and antibody testing for:

(a) all pregnant women; and

(b) all unsensitized Rh (D) negative women at twenty-four to twenty-eight weeks' gestation;

(9) behavioral counseling to prevent sexually transmitted infections in:

(a) all sexually active adolescents; and

(b) individuals aged eighteen years and older at increased risk for sexually transmitted infections;

(10) screening for hepatitis B virus infection in pregnant women;

(11) screening for human immunodeficiency virus for individuals twelve years of age and older who are at risk of human immunodeficiency virus infection;

(12) screening for iron deficiency anemia in asymptomatic pregnant women; and

(13) screening for syphilis for:

(a) any individual at increased risk for syphilis infection; and

(b) any pregnant woman.

SECTION 31. Section 59A-23-6 NMSA 1978 (being Laws 1983, Chapter 64, Section 1, as amended) is amended to read:

"59A-23-6. ALCOHOL DEPENDENCY AND MISUSE COVERAGE.--

[(1) be subject to annual deductibles and coinsurance consistent with those imposed on other benefits within the same policy;

(2)] provide [no less than thirty days] necessary care and treatment in an alcohol dependency and misuse treatment center and [thirty] outpatient visits for alcohol dependency and misuse treatment [and

(3) be offered for benefit periods of no more than one year and may be limited to a lifetime maximum of no less than two benefit periods. Such offer of benefits shall be subject to the rights of the group health insurance holder to reject the coverage or to select any alternative level of benefits if that right is offered by or negotiated with that insurer].

(1) is affiliated with a hospital under a contractual agreement with an established system for patient referral;

(2) is accredited as such a facility by the joint commission [on accreditation of hospitals]; or

(3) meets at least the minimum standards adopted by the behavioral health services division for treatment of [alcoholism] alcohol dependency and misuse in regional treatment centers.

C. This section applies to policies delivered or issued for delivery or renewed, extended or amended in this state on or after July 1, 1983 or upon expiration of a collective bargaining agreement applicable to a particular policyholder, whichever is later; provided that this section does not apply to blanket, short-term travel, accident-only, limited or specified disease, individual conversion policies or policies designed for issuance to persons eligible for coverage under Title 18 of the Social Security Act, known as medicare, or any other similar coverage under state or federal governmental plans. With respect to any policy forms approved by the insurance division of the public regulation commission prior to the effective date of this section, an insurer is authorized to comply with this section by the use of endorsements or riders, provided such endorsements or riders are approved by the insurance division as being in compliance with this section and applicable provisions of the Insurance Code.

SECTION 32. Section 59A-23-7.2 NMSA 1978 (being Laws 1994, Chapter 64, Section 5, as amended) is amended to read:

"59A-23-7.2. COVERAGE OF CHILDREN.--