2020 New Mexico Statutes
Chapter 59A - Insurance Code
Article 47 - Nonprofit Health Care Plans
Section 59A-47-45 - Coverage for autism spectrum disorder diagnosis and treatment.

A. An individual or group health insurance policy, health care plan or certificate of health insurance delivered or issued for delivery in this state shall provide coverage to a subscriber 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 subscriber's treating physician in accordance with a treatment plan;

(2) shall not be subject to any annual or lifetime dollar limits;

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

(4) may be subject to other general exclusions and limitations of the health care plan, including 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) 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. Coverage for treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis shall not be denied to a subscriber on the basis of the subscriber's age.

D. The coverage required pursuant to Subsection A of this section shall not be subject to deductibles or coinsurance provisions that are less favorable to an insured than the deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health maintenance contract, except as otherwise provided in Subsection B of this section.

E. A health care plan shall not deny or refuse to issue health care plan 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.

F. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health care plan to pay claims appropriately. These elements include:

(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.

G. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health care plan.

H. The provisions of this section shall not apply to plans, contracts or policies 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 plans, contracts or policies.

I. As used in this section:

(1) "autism spectrum disorder" means:

(a) a condition that meets the diagnostic criteria for autism spectrum disorder published in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; or

(b) a condition diagnosed as autistic disorder, Asperger's disorder, pervasive development disorder not otherwise specified, Rett's disorder or childhood disintegrative disorder pursuant to diagnostic criteria published in a previous edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; and

(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.

History: Laws 2009, ch. 74, § 4; 2019, ch. 119, § 6.

The 2019 amendment, effective June 14, 2019, prohibited age and dollar limits on services related to autism spectrum disorder, and made conforming changes; in Subsection A, in the introductory clause, after "provide coverage to", deleted "an eligible individual who is twenty-two years of age or younger and is enrolled in high school" and added "a subscriber"; in Subsection B, Paragraph B(1), after "prescribe by the", deleted "insured's" and added "subscriber's", in Paragraph B(2), deleted "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" and added "not be subject to annual or lifetime dollar limits", in Paragraph B(4), after "exclusions and limitations of the", deleted "insurer's policy or plan" and added "health care plan"; added a new Subsection C and redesignated former Subsections C through H as Subsections D through I; in Subsection D, after "subject to", deleted "dollar limits", after "favorable to an insured than the", deleted "dollar limits"; in Subsection E, deleted "An insurer" and added "A health care plan", and after "refuse to issue health", deleted "insurance" and added "care plan"; in Subsection F, in the introductory paragraph, after "health", deleted "insurance" and added "care"; in Subsection G, after "available to an insured under a health", deleted "insurance" and added "care; in Subsection H, after "shall not apply to", added "plans, contracts or", and after "benefit health insurance", added "plans, contracts or"; and in Subsection I, Subparagraph I(1)(a), after "diagnostic criteria for", deleted "the pervasive developmental disorders" and added "autism spectrum disorder", and after "American psychiatric association", deleted "including autistic disorder; Asperger's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder", added new Subparagraph I(1)(b), and deleted former Paragraph I(3), which defined "high school".