0001| AN ACT | 0002| RELATING TO HEALTH INSURANCE; REQUIRING COVERAGE FOR INDIVIDUALS | 0003| WITH DIABETES; AMENDING AND ENACTING SECTIONS OF THE NMSA 1978. | 0004| | 0005| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0006| Section 1. A new section of the New Mexico Insurance Code, Section 59A-22-41 NMSA | 0007| 1978, is enacted to read: | 0008| "59A-22-41. COVERAGE FOR INDIVIDUALS WITH DIABETES.-- | 0009| A. Each individual and group health insurance policy, health care plan, certificate | 0010| of health insurance and managed health care plan delivered or issued for delivery in this state | 0011| shall provide coverage for individuals with insulin-using diabetes, with non-insulin-using | 0012| diabetes and with elevated blood glucose levels induced by pregnancy. This coverage shall be a | 0013| basic health care benefit and shall entitle each individual to the medically accepted standard of | 0014| medical care for diabetes and benefits for diabetes treatment as well as diabetes supplies, and this | 0015| coverage shall not be reduced or eliminated. | 0016| B. Coverage for individuals with diabetes may be subject to deductibles and | 0017| coinsurance consistent with those imposed on other benefits under the same policy, plan or | 0018| certificate, as long as the annual deductibles or coinsurance for benefits are no greater than the | 0019| annual deductibles or coinsurance established for similar benefits within a given policy. | 0020| C. When prescribed or diagnosed by a health care practitioner with prescribing | 0021| authority, all individuals with diabetes as described in Subsection A of this section enrolled in | 0022| health policies described in that subsection shall be entitled to the following equipment, supplies | 0023| and appliances to treat diabetes: | 0024| (1) blood glucose monitors, including those for the legally blind; | 0025| (2) test strips for blood glucose monitors; | 0001| (3) visual reading urine and ketone strips; | 0002| (4) lancets and lancet devices; | 0003| (5) insulin; | 0004| (6) injection aids, including those adaptable to meet the needs of the | 0005| legally blind; | 0006| (7) syringes; | 0007| (8) prescriptive oral agents for controlling blood sugar levels; | 0008| (9) medically necessary podiatric appliances for prevention of feet | 0009| complications associated with diabetes, including therapeutic molded or depth-inlay shoes, | 0010| functional orthotics, custom molded inserts, replacement inserts, preventive devices and shoe | 0011| modifications for prevention and treatment; and | 0012| (10) glucagon emergency kits. | 0013| D. When prescribed or diagnosed by a health care practitioner with prescribing | 0014| authority, all individuals with diabetes as described in Subsection A of this section enrolled in | 0015| health policies described in that subsection shall be entitled to the following basic health care | 0016| benefits: | 0017| (1) diabetes self-management training that shall be provided by a certified, | 0018| registered or licensed health care professional with recent education in diabetes management, | 0019| which shall be limited to: | 0020| (a) medically necessary visits upon the diagnosis of diabetes; | 0021| (b) visits following a physician diagnosis that represents a | 0022| significant change in the patient's symptoms or condition that warrants changes in the patient's | 0023| self-management; and | 0024| (c) visits when re-education or refresher training is prescribed by a | 0025| health care practitioner with prescribing authority; and | 0001| (2) medical nutrition therapy related to diabetes management. | 0002| E. When new or improved equipment, appliances, prescription drugs for the | 0003| treatment of diabetes, insulin or supplies for the treatment of diabetes are approved by the food | 0004| and drug administration, all individual or group health insurance policies as described in | 0005| Subsection A of this section shall: | 0006| (1) maintain an adequate formulary to provide these resources to | 0007| individuals with diabetes; and | 0008| (2) guarantee reimbursement or coverage for the equipment, appliances, | 0009| prescription drug, insulin or supplies described in this subsection within the limits of the health | 0010| care plan, policy or certificate. | 0011| F. The provisions of Subsections A through E of this section shall be enforced by | 0012| the superintendent. | 0013| G. The provisions of this section shall not apply to short-term travel, accident- | 0014| only or limited or specified disease policies. | 0015| H. For purposes of this section: | 0016| (1) "basic health care benefits": | 0017| (a) means benefits for medically necessary services consisting of | 0018| preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic | 0019| laboratory and diagnostic and therapeutic radiological services; and | 0020| (b) does not include mental health services or services for alcohol | 0021| or drug abuse, dental or vision services or long-term rehabilitation treatment; and | 0022| (2) "managed health care plan" means a health benefit plan offered by a | 0023| health care insurer that provides for the delivery of comprehensive basic health care services and | 0024| medically necessary services to individuals enrolled in the plan through its own employed health | 0025| care providers or by contracting with selected or participating health care providers. A managed | 0001| health care plan includes only those plans that provide comprehensive basic health care services | 0002| to enrollees on a prepaid, capitated basis, including the following: | 0003| (a) health maintenance organizations; | 0004| (b) preferred provider organizations; | 0005| (c) individual practice associations; | 0006| (d) competitive medical plans; | 0007| (e) exclusive provider organizations; | 0008| (f) integrated delivery systems; | 0009| (g) independent physician-provider organizations; | 0010| (h) physician hospital-provider organizations; and | 0011| (i) managed care services organizations." | 0012| Section 2. Section 59A-23-4 NMSA 1978 (being Laws 1984, Chapter 127, Section 463, | 0013| as amended) is amended to read: | 0014| "59A-23-4. OTHER PROVISIONS APPLICABLE.-- | 0015| A. No blanket or group health insurance policy or contract shall contain any | 0016| provision relative to notice or proof of loss or the time for paying benefits or the time within | 0017| which suit may be brought upon the policy that in the superintendent's opinion is less favorable | 0018| to the insured than would be permitted in the required or optional provisions for individual health | 0019| insurance policies as set forth in Chapter 59A, Article 22 NMSA 1978. | 0020| B. The following provisions of Chapter 59A, Article 22 NMSA 1978 shall also | 0021| apply as to Chapter 59A, Article 23 NMSA 1978 and blanket and group health insurance | 0022| contracts: | 0023| (1) Section 59A-22-1 NMSA 1978, except Subsection C of that section; | 0024| and | 0025| (2) Section 59A-22-32 NMSA 1978. | 0001| C. The following provisions of Chapter 59A, Article 22 NMSA 1978 shall also | 0002| apply as to group health insurance contracts: | 0003| (1) Section 59A-22-33 NMSA 1978; | 0004| (2) Section 59A-22-34 NMSA 1978; | 0005| (3) Section 59A-22-34.1 NMSA 1978; | 0006| (4) Section 59A-22-35 NMSA 1978; | 0007| (5) Section 59A-22-36 NMSA 1978; | 0008| (6) Section 59A-22-39 NMSA 1978; | 0009| (7) Section 59A-22-40 NMSA 1978; and | 0010| (8) Section 59A-22-41 NMSA 1978." | 0011| Section 3. A new section of the Health Maintenance Organization Law, Section 59A-46- | 0012| 43 NMSA 1978, is enacted to read: | 0013| "59A-46-43. COVERAGE FOR INDIVIDUALS WITH DIABETES.-- | 0014| A. Each individual and group health maintenance organization contract delivered | 0015| or issued for delivery in this state shall provide coverage for individuals with insulin-using | 0016| diabetes, with non-insulin-using diabetes and with elevated blood glucose levels induced by | 0017| pregnancy. This coverage shall be a basic health care service and shall entitle each individual to | 0018| the medically accepted standard of medical care for diabetes and benefits for diabetes treatment | 0019| as well as diabetes supplies, and this coverage shall not be reduced or eliminated. | 0020| B. Coverage for individuals with diabetes may be subject to deductibles and | 0021| coinsurance consistent with those imposed on other benefits under the same contract, as long as | 0022| the annual deductibles or coinsurance for benefits are no greater than the annual deductibles or | 0023| coinsurance established for similar benefits within a given contract. | 0024| C. When prescribed or diagnosed by a health care practitioner with prescribing | 0025| authority, all individuals with diabetes as described in Subsection A of this section enrolled | 0001| under an individual or group health maintenance organization contract shall be entitled to the | 0002| following equipment, supplies and appliances to treat diabetes: | 0003| (1) blood glucose monitors, including those for the legally blind; | 0004| (2) test strips for blood glucose monitors; | 0005| (3) visual reading urine and ketone strips; | 0006| (4) lancets and lancet devices; | 0007| (5) insulin; | 0008| (6) injection aids, including those adaptable to meet the needs of the | 0009| legally blind; | 0010| (7) syringes; | 0011| (8) prescriptive oral agents for controlling blood sugar levels; | 0012| (9) medically necessary podiatric appliances for prevention of feet | 0013| complications associated with diabetes, including therapeutic molded or depth-inlay shoes, | 0014| functional orthotics, custom molded inserts, replacement inserts, preventive devices and shoe | 0015| modifications for prevention and treatment; and | 0016| (10) glucagon emergency kits. | 0017| D. When prescribed or diagnosed by a health care practitioner with prescribing | 0018| authority, all individuals with diabetes as described in Subsection A of this section enrolled | 0019| under an individual or group health maintenance contract shall be entitled to the following basic | 0020| health care services: | 0021| (1) diabetes self-management training that shall be provided by a certified, | 0022| registered or licensed health care professional with recent education in diabetes management, | 0023| which shall be limited to: | 0024| (a) medically necessary visits upon the diagnosis of diabetes; | 0025| (b) visits following a physician diagnosis that represents a | 0001| significant change in the patient's symptoms or condition that warrants changes in the patient's | 0002| self-management; and | 0003| (c) visits when re-education or refresher training is prescribed by a | 0004| health care practitioner with prescribing authority; and | 0005| (2) medical nutrition therapy related to diabetes management. | 0006| E. When new or improved equipment, appliances, prescription drugs for the | 0007| treatment of diabetes, insulin or supplies for the treatment of diabetes are approved by the food | 0008| and drug administration, each individual or group health maintenance organization contract shall: | 0009| (1) maintain an adequate formulary to provide these resources to | 0010| individuals with diabetes; and | 0011| (2) guarantee reimbursement or coverage for the equipment, appliances, | 0012| prescription drug, insulin or supplies described in this subsection within the limits of the health | 0013| care plan, policy or certificate. | 0014| F. The provisions of Subsections A through E of this section shall be enforced by | 0015| the superintendent. | 0016| G. The provisions of this section shall not apply to short-term travel, accident- | 0017| only or limited or specified disease policies." | 0018| Section 4. Section 59A-47-33 NMSA 1978 (being Laws 1984, Chapter 127, Section | 0019| 879.32, as amended by Laws 1994, Chapter 64, Section 10 and also by Laws 1994, Chapter 75, | 0020| Section 34) is amended to read: | 0021| "59A-47-33. OTHER PROVISIONS APPLICABLE.--The provisions of the Insurance | 0022| Code other than Chapter 59A, Article 47 NMSA 1978 shall not apply to health care plans except | 0023| as expressly provided in the Insurance Code and that article. To the extent reasonable and not | 0024| inconsistent with the provisions of that article, the following articles and provisions of the | 0025| Insurance Code shall also apply to health care plans, their promoters, sponsors, directors, | 0001| officers, employees, agents, solicitors and other representatives; and, for the purposes of such | 0002| applicability, a health care plan may therein be referred to as an "insurer": | 0003| A. Chapter 59A, Article 1 NMSA 1978; | 0004| B. Chapter 59A, Article 2 NMSA 1978; | 0005| C. Chapter 59A, Article 4 NMSA 1978; | 0006| D. Subsection C of Section 59A-5-22 NMSA 1978; | 0007| E. Sections 59A-6-2 through 59A-6-4 and | 0008| 59A-6-6 NMSA 1978; | 0009| F. Section 59A-7-11 NMSA 1978; | 0010| G. Chapter 59A, Article 8 NMSA 1978; | 0011| H. Chapter 59A, Article 10 NMSA 1978; | 0012| I. Section 59A-12-22 NMSA 1978; | 0013| J. Chapter 59A, Article 16 NMSA 1978; | 0014| K. Chapter 59A, Article 18 NMSA 1978; | 0015| L. Chapter 59A, Article 19 NMSA 1978; | 0016| M. Subsections B through E of Section | 0017| 59A-22-5 NMSA 1978; | 0018| N. Section 59A-22-34.1 NMSA 1978; | 0019| O. Section 59A-22-39 NMSA 1978; | 0020| P. Section 59A-22-40 NMSA 1978; | 0021| Q. Section 59A-22-41 NMSA 1978; | 0022| R. Sections 59A-34-9 through 59A-34-13 and 59A-34-23 NMSA 1978; | 0023| S. Chapter 59A, Article 37 NMSA 1978, except Section 59A-37-7 NMSA 1978; | 0024| and | 0025| T. Section 59A-46-15 NMSA 1978." | 0001| Section 5. EFFECTIVE DATE.--The effective date of the provisions of this act is | 0002| January 1, 1998. |