WHEELCHAIR INSURANCE COVERAGE

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AN ACT
RELATING TO INSURANCE; AMENDING SECTIONS OF THE HEALTH CARE
PURCHASING ACT AND THE NEW MEXICO INSURANCE CODE TO REQUIRE
COVERAGE FOR COMPLEX REHABILITATION TECHNOLOGY DEVICES;
PROVIDING THAT DENIAL OF A COMPLEX REHABILITATION TECHNOLOGY
DEVICE WITH RESPECT TO A HEALTH BENEFITS PLAN IS AN UNFAIR
AND DECEPTIVE PRACTICE IN CERTAIN CIRCUMSTANCES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. Section 13-7-46 NMSA 1978 (being Laws 2023,
Chapter 196, Section 1) is amended to read:
"13-7-46. PROSTHETIC DEVICES--CUSTOM ORTHOTIC DEVICES--
COMPLEX REHABILITATION TECHNOLOGY DEVICES--MINIMUM
COVERAGE.--
A. Group health coverage, including any form of
self-insurance, offered, issued or renewed under the Health
Care Purchasing Act shall provide coverage for prosthetic
devices, custom orthotic devices and complex rehabilitation
technology devices that is at least equivalent to that
coverage currently provided by the federal medicare program
and no less favorable than the terms and conditions that the
group health plan offers for medical and surgical benefits.
Covered benefits shall be provided for more than one
prosthetic device or custom orthotic device when medically
necessary, but shall include no more than three prosthetic
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devices or custom orthotic devices per affected limb per
covered person; provided that if after three years, a
prosthetic device or custom orthotic device is no longer the
appropriate device to meet the enrollee's needs for the
enrollee's preferred physical activity, coverage and payment
for new or replacement devices shall not be limited to three
prosthetic or custom orthotic devices per affected limb per
covered person. A group health plan shall cover:
(1) the most appropriate prosthetic device
or custom orthotic device determined to be medically
necessary by the enrollee's treating physician and associated
medical providers to restore or maintain the ability to
complete activities of daily living or essential job-related
activities. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of its design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use it;
(c) instructing the enrollee in the use
of it; and
(d) the repair and replacement of it;
(2) a prosthetic device or a custom orthotic
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device determined by the enrollee's provider to be the most
appropriate model that meets the medical needs of the
enrollee for performing physical activities, including
running, biking and swimming, and to maximize the enrollee's
upper limb function. This coverage shall include all
services and supplies necessary for the effective use of a
prosthetic device or a custom orthotic device, including:
(a) formulation of its design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use it;
(c) instructing the enrollee in the use
of it; and
(d) the repair and replacement of it;
and
(3) a prosthetic device or custom orthotic
device determined by the enrollee's prosthetic or orthotic
care provider to be the most appropriate prosthetic device or
custom orthotic device that meets the medical needs of the
enrollee for purposes of showering or bathing.
B. Coverage for complex rehabilitation technology
devices shall be based on an enrollee's specific medical,
physical, functional and environmental needs and capacities
to engage in normal life activities and shall allow an
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enrollee to obtain more than one complex rehabilitation
technology device, but no more than two complex
rehabilitation technology devices per covered person;
provided that if after three years, a complex rehabilitation
technology device is no longer the appropriate device to meet
the enrollee's needs for the enrollee's preferred physical
activity, coverage and payment for new or replacement devices
shall not be limited to two complex rehabilitation technology
devices per covered person. A group health plan shall cover:
(1) complex rehabilitation technology
devices for daily use that meet the enrollee's mobility and
positioning needs;
(2) complex rehabilitation technology
devices to enable the enrollee to participate in physical
activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for
the effective use of a complex rehabilitation technology
device, including:
(a) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person, including the formulation of the device's design,
fabrication, material and component selection and
measurements;
(b) all materials and components
necessary to use the device;
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(c) instructing the enrollee in the use
of the device; and
(d) the repair and replacement of the
device.
C. A group health plan's reimbursement rate for
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices shall be at least
equivalent to that currently provided by the federal medicare
program and no more restrictive than other coverage under the
group health plan.
D. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall be
comparable to coverage for other medical and surgical
benefits under the group health plan, including restorative
internal devices such as internal prosthetic devices, and
shall not be subject to spending limits or lifetime
restrictions.
E. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall not
be subject to separate financial requirements that are
applicable only with respect to that coverage. A group
health plan may impose cost sharing on prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices; provided that any cost-sharing requirements shall
not be more restrictive than the cost-sharing requirements
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applicable to the plan's medical and surgical benefits,
including those for internal devices.
F. A group health plan may limit the coverage for,
or alter the cost-sharing requirements for, out-of-network
coverage of prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices; provided that the
restrictions and cost-sharing requirements applicable to
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices shall not be more
restrictive than the restrictions and requirements applicable
to the out-of-network coverage for a group health plan's
medical and surgical coverage.
G. In the event that medically necessary covered
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices are not available from an
in-network provider, the insurer shall provide processes to
refer a member to an out-of-network provider and shall fully
reimburse the out-of-network provider at a mutually agreed
upon rate less member cost sharing determined on an in-
network basis.
H. A group health plan shall not impose any annual
or lifetime dollar maximum on coverage for prosthetic
devices, custom orthotic devices or complex rehabilitation
technology devices other than an annual or lifetime dollar
maximum that applies in the aggregate to all terms and
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services covered under the group health plan.
I. If coverage is provided through a managed care
plan, an enrollee shall have access to medically necessary
clinical care and to prosthetic devices, custom orthotic
devices or complex rehabilitation technology devices
and technology from not less than two distinct prosthetic
device, custom orthotic device or complex rehabilitation
technology device providers in the managed care plan's
provider network located in the state.
J. Coverage for prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
shall be considered habilitative or rehabilitative benefits
for purposes of any state or federal requirement for coverage
of essential health benefits, including habilitative and
rehabilitative benefits.
K. If coverage for prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
is provided, payment shall be made for the replacement of a
prosthetic device, a custom orthotic device or a complex
rehabilitation technology device or for the replacement of
any part of such devices, without regard to continuous use or
useful lifetime restrictions, if an ordering health care
provider determines that the provision of a replacement
device, or a replacement part of such a device, is necessary
because of any of the following:
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(1) a change in the physiological condition
of the patient;
(2) an irreparable change in the condition
of the device or in a part of the device; or
(3) the condition of the device or the part
of the device requires repairs, and the cost of such repairs
would be more than sixty percent of the cost of a replacement
device or of the part being replaced.
L. A complex rehabilitation technology device that
is a manual or power wheelchair shall only be covered
pursuant to this section if the:
(1) enrollee has undergone a complex
rehabilitation technology device evaluation conducted by a
licensed physical therapist or occupational therapist who has
no financial relationship with the supplier of the complex
rehabilitation technology device; and
(2) complex rehabilitation technology device
is provided by a complex rehabilitation technology device
supplier that:
(a) employs at least one assistive
technology professional certified by the rehabilitation
engineering and assistive technology society of North America
who specialized in seating, positioning and mobility and has
direct, in-person involvement in the wheelchair selection for
the enrollee; and
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(b) makes at least one qualified
complex rehabilitation technology device service technician
available in each service area served by the supplier to
service and repair devices that are furnished by the
supplier.
M. Confirmation from a prescribing health care
provider may be required if the prosthetic device, custom
orthotic device or complex rehabilitation technology device
or part being replaced is less than three years old.
N. A group health plan subject to the Health Care
Purchasing Act shall not discriminate against individuals
based on disability, including limb loss, absence or
malformation.
O. As used in this section, "complex
rehabilitation technology device" means a subset of durable
medical equipment that:
(1) consists of complex rehabilitation
manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(2) is designed, manufactured, configured,
adjusted or modified for a specific person to meet that
person's unique medical, physical, functional and
environmental needs and capacities;
(3) is generally not useful to a person in
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the absence of a disability, illness, injury or other medical
condition; and
(4) requires specialized services to ensure
appropriate use of the item, including:
(a) an evaluation of the features and
functions necessary to assist the person who will use the
device; or
(b) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person."
SECTION 2. Section 59A-16-21.4 NMSA 1978 (being Laws
2023, Chapter 196, Section 2) is amended to read:
"59A-16-21.4. UNFAIR TRADE PRACTICES ON THE BASIS OF
DISABILITY PROHIBITED.--
A. Any of the following practices with respect to
a health benefits plan are defined as unfair and deceptive
practices and are prohibited:
(1) canceling or changing the premiums,
benefits or conditions of a health benefits plan on the basis
of an insured's actual or perceived disability;
(2) denying a prosthetic device, a custom
orthotic device or a complex rehabilitation technology device
benefit for a person with limb loss, limb absence or mobility
limitation that would otherwise be covered for a non-disabled
person seeking medical or surgical intervention to restore or
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maintain the ability to perform the same physical activity;
(3) failure to apply the most recent version
of treatment and fit criteria developed by the professional
association with the most relevant clinical specialty when
performing a utilization review for a request for coverage of
prosthetic device, custom orthotic device or complex
rehabilitation technology device benefits; and
(4) failure to apply medical necessity
review standards developed by the professional association
with the most relevant clinical specialty when conducting
utilization management review or processing appeals regarding
benefit denial.
B. For purposes of this section:
(1) "complex rehabilitation technology
device" means a subset of durable medical equipment that:
(a) consists of complex rehabilitation
manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(b) is designed, manufactured,
configured, adjusted or modified for a specific person to
meet that person's unique medical, physical, functional and
environmental needs and capacities;
(c) is generally not useful to a person
in the absence of a disability, illness, injury or other
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medical condition; and
(d) requires specialized services to
ensure appropriate use of the item, including: 1) an
evaluation of the features and functions necessary to assist
the person who will use the device; or 2) configuring,
fitting, programming, adjusting or adapting the particular
device for use by a person; and
(2) "health benefits plan" means a policy or
agreement entered into, offered or issued by a health
insurance carrier to provide, deliver, arrange for, pay for
or reimburse the costs of health care services; provided that
"health benefits plan" does not include the following:
(a) an accident-only policy;
(b) a credit-only policy;
(c) a long- or short-term care or
disability income policy;
(d) a specified disease policy;
(e) coverage provided pursuant to Title
18 of the federal Social Security Act, as amended;
(f) coverage provided pursuant to Title
19 of the federal Social Security Act and the Public
Assistance Act;
(g) a federal TRICARE policy, including
a federal civilian health and medical program of the
uniformed services supplement;
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(h) a fixed or hospital indemnity
policy;
(i) a dental-only policy;
(j) a vision-only policy;
(k) a workers' compensation policy;
(l) an automobile medical payment
policy; or
(m) any other policy specified in rules
of the superintendent."
SECTION 3. Section 59A-22-62 NMSA 1978 (being Laws
2023, Chapter 196, Section 3) is amended to read:
"59A-22-62. MEDICAL NECESSITY AND NONDISCRIMINATION
STANDARDS FOR COVERAGE OF PROSTHETIC DEVICES, CUSTOM ORTHOTIC
DEVICES OR COMPLEX REHABILITATION TECHNOLOGY DEVICES.--
A. An individual health plan that is delivered,
issued for delivery or renewed in this state that offers
coverage for prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices shall consider
these benefits habilitative or rehabilitative benefits for
purposes of any state or federal requirement for coverage of
essential health benefits.
B. When performing a utilization review for a
request for coverage of prosthetic device, custom orthotic
device or complex rehabilitation technology device benefits,
an insurer shall apply the most recent version of evidence-
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based treatment and fit criteria as recognized by relevant
clinical specialists or their organizations. Such standards
may be named by the superintendent in rule.
C. An insurer shall render utilization review
determinations in a nondiscriminatory manner and shall not
deny coverage for habilitative or rehabilitative benefits,
including prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices, solely on the
basis of an insured's actual or perceived disability.
D. An insurer shall not deny a prosthetic device,
a custom orthotic device or a complex rehabilitation
technology device benefit for a person with limb loss, limb
absence or mobility limitation that would otherwise be
covered for a non-disabled person seeking medical or surgical
intervention to restore or maintain the ability to perform
the same physical activity.
E. An individual health plan that is delivered,
issued for delivery or renewed in this state that offers
coverage for prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices shall include
language describing an insured's rights pursuant to
Subsections C and D of this section in its evidence of
coverage and any benefit denial letters.
F. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall not
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be subject to separate financial requirements that are
applicable only with respect to that coverage. An individual
health plan may impose cost sharing on prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices; provided that any cost-sharing requirements shall
not be more restrictive than the cost-sharing requirements
applicable to the plan's coverage for inpatient physician and
surgical services.
G. An individual health plan that provides
coverage for services related to prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
shall ensure access to medically necessary clinical care and
to prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices and technology from not
less than two distinct prosthetic device, custom orthotic
device or complex rehabilitation technology device providers
in the plan's provider network located in the state. In the
event that medically necessary covered prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices are not available from an in-network provider, the
insurer shall provide processes to refer an insured to an
out-of-network provider and shall fully reimburse the out-of-
network provider at a mutually agreed upon rate less insured
cost sharing determined on an in-network basis.
H. If coverage for prosthetic devices, custom
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orthotic devices or complex rehabilitation technology devices
is provided, payment shall be made for the replacement of a
prosthetic device, a custom orthotic device or a complex
rehabilitation technology device or for the replacement of
any part of such devices, without regard to continuous use or
useful lifetime restrictions, if an ordering health care
provider determines that the provision of a replacement
device, or a replacement part of such a device, is necessary
because of any of the following:
(1) a change in the physiological condition
of the patient;
(2) an irreparable change in the condition
of the device or in a part of the device; or
(3) the condition of the device or the part
of the device requires repairs, and the cost of such repairs
would be more than sixty percent of the cost of a replacement
device or of the part being replaced.
I. Covered benefits for prosthetic devices and
custom orthotic devices shall provide for more than one
prosthetic device or custom orthotic device when medically
necessary, but shall include no more than three prosthetic
devices or custom orthotic devices per affected limb per
covered person; provided that if after three years, a
prosthetic device or custom orthotic device is no longer the
appropriate device to meet the insured's needs for the
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insured's preferred physical activity, coverage and payment
for new or replacement devices shall not be limited to three
prosthetic or custom orthotic devices per affected limb per
covered person. An individual health plan shall cover:
(1) the most appropriate prosthetic device
or custom orthotic device determined to be medically
necessary by the insured's treating physician and associated
medical providers to restore or maintain the ability to
complete activities of daily living or essential job-related
activities. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
(d) the repair and replacement of the
device;
(2) a prosthetic device or a custom orthotic
device determined by the insured's provider to be the most
appropriate model that meets the medical needs of the insured
for performing physical activities, including running, biking
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and swimming, and to maximize the insured's upper limb
function. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
(d) the repair and replacement of the
device; and
(3) a prosthetic device or custom orthotic
device determined by the insured's prosthetic or orthotic
care provider to be the most appropriate prosthetic device or
custom orthotic device that meets the medical needs of the
insured for purposes of showering or bathing.
J. Coverage for complex rehabilitation technology
devices shall be based on an insured's specific medical,
physical, functional and environmental needs and capacities
to engage in normal life activities and shall allow an
insured to obtain more than one complex rehabilitation
technology device, but no more than two complex
rehabilitation technology devices per covered person;
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provided that if after three years, a complex rehabilitation
technology device is no longer the appropriate device to meet
the insured's needs for the insured's preferred physical
activity, coverage and payment for new or replacement devices
shall not be limited to two complex rehabilitation technology
devices per covered person. An individual health plan shall
cover:
(1) complex rehabilitation technology
devices for daily use that meets the insured's mobility and
positioning needs;
(2) complex rehabilitation technology
devices to enable the insured to participate in physical
activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for
the effective use of a complex rehabilitation technology
device, including:
(a) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person, including the formulation of the device's design,
fabrication, material and component selection and
measurements;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
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(d) the repair and replacement of the
device.
K. A complex rehabilitation technology device that
is a manual or power wheelchair shall only be covered
pursuant to this section if the:
(1) insured has undergone a complex
rehabilitation technology device evaluation conducted by a
licensed physical therapist or occupational therapist who has
no financial relationship with the supplier of the complex
rehabilitation technology device; and
(2) complex rehabilitation technology device
is provided by a complex rehabilitation technology device
supplier that:
(a) employs at least one assistive
technology professional certified by the rehabilitation
engineering and assistive technology society of North America
who specialized in seating, positioning and mobility and has
direct, in-person involvement in the wheelchair selection for
the insured; and
(b) makes at least one qualified
complex rehabilitation technology device service technician
available in each service area served by the supplier to
service and repair devices that are furnished by the
supplier.
L. Confirmation from a prescribing health care
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provider may be required if the prosthetic device, custom
orthotic device or complex rehabilitation technology device
or part being replaced is less than three years old.
M. The provisions of this section do not apply to
excepted benefits plans subject to the Short-Term Health Plan
and Excepted Benefit Act.
N. As used in this section, "complex
rehabilitation technology device" means a subset of durable
medical equipment that:
(1) consists of complex rehabilitation
manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(2) is designed, manufactured, configured,
adjusted or modified for a specific person to meet that
person's unique medical, physical, functional and
environmental needs and capacities;
(3) is generally not useful to a person in
the absence of a disability, illness, injury or other medical
condition; and
(4) requires specialized services to ensure
appropriate use of the item, including:
(a) an evaluation of the features and
functions necessary to assist the person who will use the
device; or
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(b) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person."
SECTION 4. Section 59A-23-32 NMSA 1978 (being Laws
2023, Chapter 196, Section 4) is amended to read:
"59A-23-32. MEDICAL NECESSITY AND NONDISCRIMINATION
STANDARDS FOR COVERAGE OF PROSTHETIC DEVICES, CUSTOM ORTHOTIC
DEVICES OR COMPLEX REHABILITATION TECHNOLOGY DEVICES.--
A. A group health plan that is delivered, issued
for delivery or renewed in this state that covers essential
health benefits or covers prosthetic devices, custom orthotic
devices or complex rehabilitation technology devices shall
consider these benefits habilitative or rehabilitative
benefits for purposes of state or federal requirements on
essential health benefits coverage.
B. When performing a utilization review for a
request for coverage of prosthetic device, custom orthotic
device or complex rehabilitation technology device benefits,
an insurer shall apply the most recent version of evidence-
based treatment and fit criteria as recognized by relevant
clinical specialists or their organizations. Such standards
may be named by the superintendent in rule.
C. An insurer shall render utilization review
determinations in a nondiscriminatory manner and shall not
deny coverage for habilitative or rehabilitative benefits,
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including prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices, solely based on an
insured's actual or perceived disability.
D. An insurer shall not deny a prosthetic device,
a custom orthotic device or a complex rehabilitation
technology device benefit for a person with limb loss, limb
absence or mobility limitation that would otherwise be
covered for a non-disabled person seeking medical or surgical
intervention to restore or maintain the ability to perform
the same physical activity.
E. A group health plan that is delivered, issued
for delivery or renewed in this state that offers coverage
for prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices shall include language
describing an insured's rights pursuant to Subsections C and
D of this section in its evidence of coverage and any benefit
denial letters.
F. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall not
be subject to separate financial requirements that are
applicable only with respect to that coverage. A group
health plan may impose cost sharing on prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices; provided that any cost-sharing requirements shall
not be more restrictive than the cost-sharing requirements
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applicable to the plan's coverage for inpatient physician and
surgical services.
G. A group health plan that provides coverage for
services related to prosthetic devices, custom orthotic
devices or complex rehabilitation technology devices shall
ensure access to medically necessary clinical care and to
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices and technology from not
less than two distinct prosthetic device, custom orthotic
device or complex rehabilitation technology device providers
in the plan's provider network located in the state. In the
event that medically necessary covered prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices are not available from an in-network provider, the
insurer shall provide processes to refer an insured to an
out-of-network provider and shall fully reimburse the out-of-
network provider at a mutually agreed upon rate less insured
cost sharing determined on an in-network basis.
H. If coverage for prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
is provided, payment shall be made for the replacement of a
prosthetic device, a custom orthotic device or a complex
rehabilitation technology device or for the replacement of
any part of such devices, without regard to continuous use or
useful lifetime restrictions, if an ordering health care
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provider determines that the provision of a replacement
device, or a replacement part of such a device, is necessary
because of any of the following:
(1) a change in the physiological condition
of the patient;
(2) an irreparable change in the condition
of the device or in a part of the device; or
(3) the condition of the device or the part
of the device requires repairs, and the cost of such repairs
would be more than sixty percent of the cost of a replacement
device or of the part being replaced.
I. Covered benefits for prosthetic devices and
custom orthotic devices shall provide for more than one
prosthetic device or custom orthotic device when medically
necessary, but shall include no more than three prosthetic
devices or custom orthotic devices per affected limb per
covered person; provided that if after three years, a
prosthetic device or custom orthotic device is no longer the
appropriate device to meet the insured's needs for the
insured's preferred physical activity, coverage and payment
for new or replacement devices shall not be limited to three
prosthetic or custom orthotic devices per affected limb per
covered person. A group health plan shall cover:
(1) the most appropriate prosthetic device
or custom orthotic device determined to be medically
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necessary by the insured's treating physician and associated
medical providers to restore or maintain the ability to
complete activities of daily living or essential job-related
activities. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
(d) the repair and replacement of the
device;
(2) a prosthetic device or a custom orthotic
device determined by the insured's provider to be the most
appropriate model that meets the medical needs of the insured
for performing physical activities, including running, biking
and swimming, and to maximize the insured's upper limb
function. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
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fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
(d) the repair and replacement of the
device; and
(3) a prosthetic device or custom orthotic
device determined by the insured's prosthetic or orthotic
care provider to be the most appropriate prosthetic device or
custom orthotic device that meets the medical needs of the
insured for purposes of showering or bathing.
J. Coverage for complex rehabilitation technology
devices shall be based on an insured's specific medical,
physical, functional and environmental needs and capacities
to engage in normal life activities and shall allow an
insured to obtain more than one complex rehabilitation
technology device, but no more than two complex
rehabilitation technology devices per covered person;
provided that if after three years, a complex rehabilitation
technology device is no longer the appropriate device to meet
the insured's needs for the insured's preferred physical
activity, coverage and payment for new or replacement devices
shall not be limited to two complex rehabilitation technology
devices per covered person. A group health plan shall cover:
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(1) complex rehabilitation technology
devices for daily use that meet the insured's mobility and
positioning needs;
(2) complex rehabilitation technology
devices to enable the insured to participate in physical
activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for
the effective use of a complex rehabilitation technology
device, including:
(a) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person, including the formulation of the device's design,
fabrication, material and component selection and
measurements;
(b) all materials and components
necessary to use the device;
(c) instructing the insured in the use
of the device; and
(d) the repair and replacement of the
device.
K. A complex rehabilitation technology device that
is a manual or power wheelchair shall only be covered
pursuant to this section if the:
(1) insured has undergone a complex
rehabilitation technology device evaluation conducted by a
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licensed physical therapist or occupational therapist who has
no financial relationship with the supplier of the complex
rehabilitation technology device; and
(2) complex rehabilitation technology device
is provided by a complex rehabilitation technology device
supplier that:
(a) employs at least one assistive
technology professional certified by the rehabilitation
engineering and assistive technology society of North America
who specialized in seating, positioning and mobility and has
direct, in-person involvement in the wheelchair selection for
the insured; and
(b) makes at least one qualified
complex rehabilitation technology device service technician
available in each service area served by the supplier to
service and repair devices that are furnished by the
supplier.
L. Confirmation from a prescribing health care
provider may be required if the prosthetic device, custom
orthotic device or complex rehabilitation technology device
or part being replaced is less than three years old.
M. The provisions of this section do not apply to
excepted benefits plans subject to the Short-Term Health Plan
and Excepted Benefit Act.
N. As used in this section, "complex
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rehabilitation technology device" means a subset of durable
medical equipment that:
(1) consists of complex rehabilitation
manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(2) is designed, manufactured, configured,
adjusted or modified for a specific person to meet that
person's unique medical, physical, functional and
environmental needs and capacities;
(3) is generally not useful to a person in
the absence of a disability, illness, injury or other medical
condition; and
(4) requires specialized services to ensure
appropriate use of the item, including:
(a) an evaluation of the features and
functions necessary to assist the person who will use the
device; or
(b) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person."
SECTION 5. Section 59A-46-72 NMSA 1978 (being Laws
2023, Chapter 196, Section 5) is amended to read:
"59A-46-72. MEDICAL NECESSITY AND NONDISCRIMINATION
STANDARDS FOR COVERAGE OF PROSTHETIC DEVICES, CUSTOM ORTHOTIC
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DEVICES OR COMPLEX REHABILITATION TECHNOLOGY DEVICES.--
A. An individual or group health maintenance
organization contract that is delivered, issued for delivery
or renewed in this state that covers essential health
benefits and covers prosthetic devices, custom orthotic
devices or complex rehabilitation technology devices shall
consider these benefits habilitative or rehabilitative
benefits for purposes of state or federal requirements on
essential health benefits coverage.
B. When performing a utilization review for a
request for coverage of prosthetic device, custom orthotic
device or complex rehabilitation technology device benefits,
a health maintenance organization shall apply the most recent
version of evidence-based treatment and fit criteria as
recognized by relevant clinical specialists or their
organizations. Such standards may be named by the
superintendent in rule.
C. A health maintenance organization shall render
utilization review determinations in a nondiscriminatory
manner and shall not deny coverage for habilitative or
rehabilitative benefits, including prosthetic devices, custom
orthotic devices or complex rehabilitation technology
devices, solely based on an enrollee's actual or perceived
disability.
D. A health maintenance organization shall not
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deny a prosthetic device, a custom orthotic device or a
complex rehabilitation technology device benefit for a person
with limb loss, limb absence or mobility limitation that
would otherwise be covered for a non-disabled person seeking
medical or surgical intervention to restore or maintain the
ability to perform the same physical activity.
E. An individual or group health maintenance
organization contract that is delivered, issued for delivery
or renewed in this state that offers coverage for prosthetic
devices, custom orthotic devices or complex rehabilitation
technology devices shall include language describing an
enrollee's rights pursuant to Subsections C and D of this
section in its evidence of coverage and any benefit denial
letters.
F. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall not
be subject to separate financial requirements that are
applicable only with respect to that coverage. An individual
or group health maintenance organization contract may impose
cost sharing on prosthetic devices, custom orthotic devices
or complex rehabilitation technology devices; provided that
any cost-sharing requirements shall not be more restrictive
than the cost-sharing requirements applicable to the plan's
coverage for inpatient physician and surgical services.
G. An individual or group health maintenance
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organization contract that provides coverage for services
related to prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices shall ensure access
to medically necessary clinical care and to prosthetic
devices, custom orthotic devices or complex rehabilitation
technology devices and technology from not less than two
distinct prosthetic device, custom orthotic device or complex
rehabilitation technology device providers in the managed
care plan's provider network located in the state. In the
event that medically necessary covered prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices are not available from an in-network provider, the
health maintenance organization shall provide processes to
refer an enrollee to an out-of-network provider and shall
fully reimburse the out-of-network provider at a mutually
agreed upon rate less enrollee cost sharing determined on an
in-network basis.
H. If coverage for prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
is provided, payment shall be made for the replacement of a
prosthetic device, a custom orthotic device or a complex
rehabilitation technology device or for the replacement of
any part of such devices, without regard to continuous use or
useful lifetime restrictions, if an ordering health care
provider determines that the provision of a replacement
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device, or a replacement part of such a device, is necessary
because of any of the following:
(1) a change in the physiological condition
of the patient;
(2) an irreparable change in the condition
of the device or in a part of the device; or
(3) the condition of the device or the part
of the device requires repairs, and the cost of such repairs
would be more than sixty percent of the cost of a replacement
device or of the part being replaced.
I. Covered benefits for prosthetic devices and
custom orthotic devices shall provide for more than one
prosthetic device or custom orthotic device when medically
necessary, but shall include no more than three prosthetic
devices or custom orthotic devices per affected limb per
covered person; provided that if after three years, a
prosthetic device or custom orthotic device is no longer the
appropriate device to meet the enrollee's needs for the
enrollee's preferred physical activity, coverage and payment
for new or replacement devices shall not be limited to three
prosthetic or custom orthotic devices per affected limb per
covered person. An individual or group health maintenance
organization contract shall cover:
(1) the most appropriate prosthetic device
or custom orthotic device determined to be medically
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necessary by the enrollee's treating physician and associated
medical providers to restore or maintain the ability to
complete activities of daily living or essential job-related
activities. This coverage shall include all services and
supplies necessary for the effective use of a prosthetic
device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the enrollee in the use
of the device; and
(d) the repair and replacement of the
device;
(2) a prosthetic device or a custom orthotic
device determined by the enrollee's provider to be the most
appropriate model that meets the medical needs of the
enrollee for performing physical activities, including
running, biking and swimming, and to maximize the enrollee's
upper limb function. This coverage shall include all
services and supplies necessary for the effective use of a
prosthetic device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
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fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the enrollee in the use
of the device; and
(d) the repair and replacement of the
device; and
(3) a prosthetic device or custom orthotic
device determined by the enrollee's prosthetic or orthotic
care provider to be the most appropriate prosthetic device or
custom orthotic device that meets the medical needs of the
enrollee for purposes of showering or bathing.
J. Coverage for complex rehabilitation technology
devices shall be based on an enrollee's specific medical,
physical, functional and environmental needs and capacities
to engage in normal life activities and shall allow an
enrollee to obtain more than one complex rehabilitation
technology device, but no more than two complex
rehabilitation technology devices per covered person;
provided that if after three years, a complex rehabilitation
technology device is no longer the appropriate device to meet
the enrollee's needs for the enrollee's preferred physical
activity, coverage and payment for new or replacement devices
shall not be limited to two complex rehabilitation technology
devices per covered person. An individual or group health
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maintenance organization contract shall cover:
(1) complex rehabilitation technology
devices for daily use that meets the enrollee's mobility and
positioning needs;
(2) complex rehabilitation technology
devices to enable the enrollee to participate in physical
activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for
the effective use of a complex rehabilitation technology
device, including:
(a) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person, including the formulation of the device's design,
fabrication, material and component selection and
measurements;
(b) all materials and components
necessary to use the device;
(c) instructing the enrollee in the use
of the device; and
(d) the repair and replacement of the
device.
K. A complex rehabilitation technology device that
is a manual or power wheelchair shall only be covered
pursuant to this section if the:
(1) enrollee has undergone a complex
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rehabilitation technology device evaluation conducted by a
licensed physical therapist or occupational therapist who has
no financial relationship with the supplier of the complex
rehabilitation technology device; and
(2) complex rehabilitation technology device
is provided by a complex rehabilitation technology device
supplier that:
(a) employs at least one assistive
technology professional certified by the rehabilitation
engineering and assistive technology society of North America
who specialized in seating, positioning and mobility and has
direct, in-person involvement in the wheelchair selection for
the enrollee; and
(b) makes at least one qualified
complex rehabilitation technology device service technician
available in each service area served by the supplier to
service and repair devices that are furnished by the
supplier.
L. Confirmation from a prescribing health care
provider may be required if the prosthetic device, custom
orthotic device or complex rehabilitation technology device
or part being replaced is less than three years old.
M. The provisions of this section do not apply to
excepted benefits plans subject to the Short-Term Health Plan
and Excepted Benefit Act.
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N. As used in this section, "complex
rehabilitation technology device" means a subset of durable
medical equipment that:
(1) consists of complex rehabilitation
manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(2) is designed, manufactured, configured,
adjusted or modified for a specific person to meet that
person's unique medical, physical, functional and
environmental needs and capacities;
(3) is generally not useful to a person in
the absence of a disability, illness, injury or other medical
condition; and
(4) requires specialized services to ensure
appropriate use of the item, including:
(a) an evaluation of the features and
functions necessary to assist the person who will use the
device; or
(b) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person."
SECTION 6. Section 59A-47-66 NMSA 1978 (being Laws
2023, Chapter 196, Section 6) is amended to read:
"59A-47-66. MEDICAL NECESSITY AND NONDISCRIMINATION
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STANDARDS FOR COVERAGE OF PROSTHETIC DEVICES, CUSTOM ORTHOTIC
DEVICES OR COMPLEX REHABILITATION TECHNOLOGY DEVICES.--
A. An individual or group health care plan that is
delivered, issued for delivery or renewed in this state that
covers essential health benefits and covers prosthetic
devices, custom orthotic devices or complex rehabilitation
technology devices shall consider these benefits habilitative
or rehabilitative benefits for purposes of state or federal
requirements on essential health benefits coverage.
B. When performing a utilization review for a
request for coverage of prosthetic device, custom orthotic
device or complex rehabilitation technology device benefits,
a health care plan shall apply the most recent version of
evidence-based treatment and fit criteria as recognized by
relevant clinical specialists or their organizations. Such
standards may be named by the superintendent in rule.
C. A health care plan shall render utilization
review determinations in a nondiscriminatory manner and shall
not deny coverage for habilitative or rehabilitative
benefits, including prosthetic devices, custom orthotic
devices or complex rehabilitation technology devices, solely
based on a subscriber's actual or perceived disability.
D. A health care plan shall not deny a prosthetic
device, a custom orthotic device or a complex rehabilitation
technology device benefit for a person with limb loss, limb
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absence or mobility limitation that would otherwise be
covered for a non-disabled person seeking medical or surgical
intervention to restore or maintain the ability to perform
the same physical activity.
E. A health care plan that is delivered, issued
for delivery or renewed in this state that offers coverage
for prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices shall include language
describing a subscriber's rights pursuant to Subsections C
and D of this section in its evidence of coverage and any
benefit denial letters.
F. Prosthetic device, custom orthotic device or
complex rehabilitation technology device coverage shall not
be subject to separate financial requirements that are
applicable only with respect to that coverage. An individual
or group health care plan may impose cost sharing on
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices; provided that any cost-
sharing requirements shall not be more restrictive than the
cost-sharing requirements applicable to the plan's coverage
for inpatient physician and surgical services.
G. An individual or group health care plan that
provides coverage for services related to prosthetic devices,
custom orthotic devices or complex rehabilitation technology
devices shall ensure access to medically necessary clinical
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care and to prosthetic devices, custom orthotic devices or
complex rehabilitation technology devices and technology from
not less than two distinct prosthetic device, custom orthotic
device or complex rehabilitation technology device providers
in the health care plan's provider network located in the
state. In the event that medically necessary covered
prosthetic devices, custom orthotic devices or complex
rehabilitation technology devices are not available from an
in-network provider, the health care plan shall provide
processes to refer a subscriber to an out-of-network provider
and shall fully reimburse the out-of-network provider at a
mutually agreed upon rate less subscriber cost sharing
determined on an in-network basis.
H. If coverage for prosthetic devices, custom
orthotic devices or complex rehabilitation technology devices
is provided, payment shall be made for the replacement of a
prosthetic device, a custom orthotic device or a complex
rehabilitation technology device or for the replacement of
any part of such devices, without regard to continuous use or
useful lifetime restrictions, if an ordering health care
provider determines that the provision of a replacement
device, or a replacement part of such a device, is necessary
because of any of the following:
(1) a change in the physiological condition
of the patient;
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(2) an irreparable change in the condition
of the device or in a part of the device; or
(3) the condition of the device or the part
of the device requires repairs, and the cost of such repairs
would be more than sixty percent of the cost of a replacement
device or of the part being replaced.
I. Covered benefits for prosthetic devices and
custom orthotic devices shall provide for more than one
prosthetic device or custom orthotic device when medically
necessary, but shall include no more than three prosthetic
devices or custom orthotic devices per affected limb per
covered person; provided that if after three years, a
prosthetic device or custom orthotic device is no longer the
appropriate device to meet the subscriber's needs for the
subscriber's preferred physical activity, coverage and
payment for new or replacement devices shall not be limited
to three prosthetic or custom orthotic devices per affected
limb per covered person. A health care plan shall cover:
(1) the most appropriate prosthetic device
or custom orthotic device determined to be medically
necessary by the subscriber's treating physician and
associated medical providers to restore or maintain the
ability to complete activities of daily living or essential
job-related activities. This coverage shall include all
services and supplies necessary for the effective use of a
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prosthetic device or a custom orthotic device, including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the subscriber in the
use of the device; and
(d) the repair and replacement of the
device;
(2) a prosthetic device or a custom orthotic
device determined by the subscriber's provider to be the most
appropriate model that meets the medical needs of the
subscriber for performing physical activities, including
running, biking and swimming, and to maximize the
subscriber's upper limb function. This coverage shall
include all services and supplies necessary for the effective
use of a prosthetic device or a custom orthotic device,
including:
(a) formulation of the device's design,
fabrication, material and component selection, measurements,
fittings and static and dynamic alignments;
(b) all materials and components
necessary to use the device;
(c) instructing the subscriber in the
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use of the device; and
(d) the repair and replacement of the
device; and
(3) a prosthetic device or custom orthotic
device determined by the subscriber's prosthetic or orthotic
care provider to be the most appropriate prosthetic device or
custom orthotic device that meets the medical needs of the
subscriber for purposes of showering or bathing.
J. Coverage for complex rehabilitation technology
devices shall be based on a subscriber's specific medical,
physical, functional and environmental needs and capacities
to engage in normal life activities and shall allow a
subscriber to obtain more than one complex rehabilitation
technology device, but no more than two complex
rehabilitation technology devices per covered person;
provided that if after three years, a complex rehabilitation
technology device is no longer the appropriate device to meet
the subscriber's needs for the subscriber's preferred
physical activity, coverage and payment for new or
replacement devices shall not be limited to two complex
rehabilitation technology devices per covered person. A
health care plan shall cover:
(1) complex rehabilitation technology
devices for daily use that meet the subscriber's mobility and
positioning needs;
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(2) complex rehabilitation technology
devices to enable the subscriber to participate in physical
activities necessary to achieve or maintain health goals; and
(3) all services and supplies necessary for
the effective use of a complex rehabilitation technology
device, including:
(a) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person, including the formulation of the device's design,
fabrication, material and component selection and
measurements;
(b) all materials and components
necessary to use the device;
(c) instructing the subscriber in the
use of the device; and
(d) the repair and replacement of the
device.
K. A complex rehabilitation technology device that
is a manual or power wheelchair shall only be covered
pursuant to this section if the:
(1) subscriber has undergone a complex
rehabilitation technology device evaluation conducted by a
licensed physical therapist or occupational therapist who has
no financial relationship with the supplier of the complex
rehabilitation technology device; and
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(2) complex rehabilitation technology device
is provided by a complex rehabilitation technology device
supplier that:
(a) employs at least one assistive
technology professional certified by the rehabilitation
engineering and assistive technology society of North America
who specialized in seating, positioning and mobility and has
direct, in-person involvement in the wheelchair selection for
the subscriber; and
(b) makes at least one qualified
complex rehabilitation technology device service technician
available in each service area served by the supplier to
service and repair devices that are furnished by the
supplier.
L. Confirmation from a prescribing health care
provider may be required if the prosthetic device, custom
orthotic device or complex rehabilitation technology device
or part being replaced is less than three years old.
M. The provisions of this section do not apply to
excepted benefits plans subject to the Short-Term Health Plan
and Excepted Benefit Act.
N. As used in this section, "complex
rehabilitation technology device" means a subset of durable
medical equipment that:
(1) consists of complex rehabilitation
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manual and power wheelchairs and mobility devices, including
specialized seating and positioning items, options and
accessories;
(2) is designed, manufactured, configured,
adjusted or modified for a specific person to meet that
person's unique medical, physical, functional and
environmental needs and capacities;
(3) is generally not useful to a person in
the absence of a disability, illness, injury or other medical
condition; and
(4) requires specialized services to ensure
appropriate use of the item, including:
(a) an evaluation of the features and
functions necessary to assist the person who will use the
device; or
(b) configuring, fitting, programming,
adjusting or adapting the particular device for use by a
person."
SECTION 7. APPLICABILITY.--The provisions of this act
apply to policies, plans, contracts and certificates delivered
or issued for delivery or renewed, extended or amended in this
state on or after January 1, 2027.