NMSA 59A-23-32. Medical necessity and nondiscrimination standards for

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, 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 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 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 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, 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: (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 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 [Chapter 59A, Article 23G NMSA 1978]. 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. History: Laws 2023, ch. 196, § 4; 2026, ch. 41, § 4. ARTICLE 23A Long-Term Care Insurance