New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 13 - MANAGED HEALTH CARE - BENEFITS
Section 13.10.13.9 - SUPPLEMENTAL HEALTH CARE SERVICES
Universal Citation: 13 NM Admin Code 13.10.13.9
Current through Register Vol. 35, No. 18, September 24, 2024
A. A health care insurer, through its MHCP, may provide to its covered persons supplemental health care services that are not basic health care services. For HMOs, basic health care services are defined and described at 13.10.21.8 NMAC. These supplemental health care services may be limited as to time and cost.
B. Additional fees: A health care insurer may determine the level and scope of any supplemental health care service provided to its covered persons in a MHCP, whether or not the service is listed in this section, and may charge additional fees for those services.
C. The following are not required as basic health care services, but may be provided as supplemental health care services:
(1) consultation with
and referral to physicians and other health care professionals such as
dentists, nurses, podiatrists, optometrists, chiropractic physicians, physician
assistants, clinical psychologists, social workers, pharmacists, nutritionists,
occupational therapists, physical therapists, certified nurse midwives and
other professionals engaged in the delivery of health services who are licensed
to practice, are certified, and are practicing under authority of the MHCP, a
medical group, an independent practice association or other authority
authorized by applicable New Mexico law when treatment exceeds that included in
basic health care services;
(2)
corrective appliances, prosthetics, and artificial aids, including hearing
aids, except as required in Section
13-7-10
NMSA 1978;
(3) mental health
services, including, but not limited to, outpatient evaluative, crisis
intervention and short term therapeutic mental health services and inpatient
psychiatric care, except as required in Section 59A-23E 18 NMSA 1978;
(4) cosmetic surgery;
(5) pharmaceuticals and other medicines
prescribed on an outpatient basis by licensed physicians nurse practitioners,
physician assistants or certified nurse-midwives to treat or prevent
illness;
(6) ambulance services,
other than for emergencies or otherwise deemed medically necessary;
(7) care for military service-connected
disabilities for which a covered person is legally entitled to services and for
which facilities are reasonably available to the covered person;
(8) care for conditions that state or local
law requires be treated in a public facility;
(9) dental services not required as a basic
health care service;
(10) vision
care;
(11) personal or comfort
items;
(12) long-term physical
therapy and rehabilitation;
(13)
durable medical equipment for home use, such as wheel chairs, surgical beds,
respirators, and dialysis machines;
(14) diagnosis, medical treatment and
referral services for the abuse of or addiction to alcohol or drugs, including
inpatient substance abuse care in a facility licensed to provide residential
alcohol and drug abuse services, except as required by Section 59A-23-6 NMSA
1978;
(15) home health care
services which, if offered, at a minimum shall comply with Section 59A-22-36
and Section 59A-46-40 NMSA 1978;
(16) skilled or intermediate nursing
care;
(17) custodial or domiciliary
care;
(18) hearing care, except as
required for children by Section 59A-22-34.5 NMSA 1978;
(19) experimental or investigational medical,
surgical, other health care procedures or treatments, including drugs, unless
approved as a basic health care service treatment or procedure by the health
care insurer. As used in this section, "experimental" or "investigational" as
related to drugs, devices, medical treatments or procedures means:
(a) the drug or device cannot be lawfully
marketed without approval of the FDA and approval for marketing has not been
given at the time the drug or device is furnished;
(b) reliable evidence shows that the drug,
device or medical treatment or procedure is the subject of on-going phase I,
II, or III clinical trials or under study to determine its maximum tolerated
dose, its toxicity, its safety, its efficacy, or its efficacy as compared with
the standard means of treatment or diagnosis;
(c) reliable evidence shows that the
consensus among experts regarding the drug, device, or medical treatment or
procedure is that further studies or clinical trials are necessary to determine
its maximum tolerated dose, toxicity, safety, or efficacy as compared with the
standard means of treatment or diagnosis; or
(d) except as required by 13.10.13.10 NMAC,
the drug or device is used for a purpose that is not approved by the
FDA;
(e) for the purposes of this
section, "reliable evidence" shall mean only published reports and articles in
the authoritative medical and scientific literature listed in Subsection A of
13.10.13.10 NMAC; the written protocol or protocols used by the treating
facility or the protocol(s) of another facility studying substantially the same
drug, device or medical treatment or procedure; or the written informed consent
used by the treating facility or by another facility studying substantially the
same drug, device or medical treatment or procedure;
(f) as used in this section, "experimental"
or "investigational" does not mean cancer chemotherapy or other types of
therapy that are the subjects of on-going phase IV clinical trials.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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