New Mexico Register / Volume XXXVII,
Issue 9 / May 5, 2026
TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 41 COVERAGE FOR SPECIFIED SEX TRAIT
MODIFICATION PROCEDURE
13.10.41.1 ISSUING AGENCY: Office of
Superintendent of Insurance.
[13.10.41.1 NMAC –
N/E, 05/05/2026]
13.10.41.2 SCOPE: This rule only applies
to health insurers who issue an individual or group health insurance policy,
health care plan or certificate of health insurance for a resident of this
state. This rule does not apply to any short-term health plan or excepted
benefits plan under Section 59A-23G-2 NMSA 1978.
[13.10.41.2 NMAC -
N/E, 05/05/2026]
13.10.41.3 STATUTORY AUTHORITY: Sections
14-4-1 et seq., NMSA 1978, State Rules Act, and Sections 59A-23E-11 and
59A-16-13 NMSA 1978.
[13.10.41.3 NMAC -
N/E, 05/05/2026]
13.10.41.4 DURATION: This emergency
rule expires 180 days from the effective date pursuant to Subsection E of
Section 14-4-5.6 NMSA 1978.
[13.10.12.4 NMAC -
N/E, 05/05/2026]
13.10.41.5 EFFECTIVE DATE: May 5, 2026,
unless a later date is cited at the end of a section. This rule applies beginning with plan year
2027 and each plan year thereafter.
[13.10.41.5 NMAC –
N/E, 05/05/2026]
13.10.41.6 OBJECTIVE: To clarify
coverage requirements for specified sex trait modification procedure healthcare
and pharmacy benefits.
[13.10.41.6 NMAC -
N/E, 05/05/2026]
13.10.41.7 DEFINITIONS: Unless
inconsistent with a term defined in this rule, or the usage of a term in this
rule, the definitions in 13.10.29 NMAC apply:
A. “BeWell” New Mexico’s health
insurance marketplace for Affordable Care Act plans;
B. “diagnosis code” means a standardized alphanumeric
code that identifies and documents a
patient’s disease,
condition, symptom, or clinical finding during a healthcare encounter, derived
from the current international classification of diseases, clinical modification
(ICD-CM) system;
C. “gender identity” means emotional, physical, and
social expression of an individual’s preferred
sex traits;
D. “health insurer” means an entity subject to the
insurance laws and regulations of this state,
including a health
insurance company, a health maintenance organization, a hospital and health
services corporation, a provider service network, a non-profit health care plan
or any other entity that contracts or offers to contract, or enters into agreements
to provide, deliver, arrange for, pay for or reimburse any costs of health care
services, or that provides, offers health benefits
plans or managed health care plans in this state;
E. “medically necessary” means health care services
determined by a provider, in consultation with
the health
insurance carrier, to be appropriate or necessary, according to:
(1) Any applicable generally accepted
principles and practices of good medical care;
(2) Practice guidelines developed by the
federal government, national or professional
medical societies,
boards and associations, or
(3) Any applicable clinical protocols or
practice guidelines developed by the health insurance
carrier consistent
with such federal, national and professional practice guidelines. These standards shall be applied to decisions
related to the diagnosis or direct care and treatment of a physical or
behavioral health condition, illness, injury or disease;
F. “procedure code” means current procedure terminology
or healthcare common procedure coding system codes, and other similar codes,
that standardize medical procedures, services, supplies, and equipment;
G. “provider” means, in addition to the definition in
Paragraph (13) of Subsection P of 13.10.29.7 NMAC, pharmacists authorized to
prescribe drugs for any specified sex trait modification procedure directly to
patients pursuant to 16.19.26.14 NMAC;
H. “specified sex trait modification procedure” has
the same meaning as defined in 45 C.F.R. Section 156.400; and
I. “superintendent” has the same meaning as defined
in Section 59A-1-12 NMSA 1978.
[13.10.41.7 NMAC -
N/E, 05/05/2026]
13.10.41.8 NONDISCRIMINATION: A health
insurer who is required to provide coverage for any specified sex trait
modification procedure under this rule shall do so without discriminating
against the covered person on the basis of race, color, national origin, sex,
sexual orientation, gender identity, marital status, age, citizenship, immigration
status, or disability.
[13.10.41.8 NMAC -
N/E, 05/05/2026]
13.10.41.9 COVERAGE REQUIREMENTS: A
health insurer has an obligation to cover any specified sex trait modification
procedure that an insured’s provider determines to be medically necessary in
consultation with the health insurer.
[13.10.41.9 NMAC -
N/E, 05/05/2026]
13.10.41.10 REQUEST TO SUPERINTENDENT FOR
DEFRAYAL:
A. Only health insurance plans sold on BeWell
are eligible for defrayal under this rule.
B. Only in-network claims, or out-of-network claims eligible
for coverage pursuant to provider network adequacy rules under 13.10.22 NMAC,
are eligible for defrayal under this rule.
C. By October 1, 2028, and each year on this date
thereafter, a health insurer seeking defrayal of costs for the previous plan
year under this rule shall provide information related to claims incurred during
the prior full calendar year for specified sex trait modification procedures, including,
but not limited to, the content specified in (1)-(6) below on a standard form
that the superintendent provides:
(1) all procedure and diagnosis
codes;
(2) the number of claims per
procedure code;
(3) all costs per procedure code;
(4) all national drug codes;
(5) the number of prescription drug
claims per national drug code;
(6) all costs per national drug code.
D. After consultation with the health insurers, the superintendent
shall determine diagnosis, procedure, and drug codes for plans eligible for
defrayal and apply this determination equitably to all health insurers.
E. The superintendent shall publish the diagnosis,
procedure, and drug codes for plans eligible for defrayal on the OSI website.
F. The superintendent shall not use federal funds for
defrayal of costs associated with specified sex trait modification procedures.
G. Health insurers shall create an allocation account with
adequate funds through which they exclusively administer claims for all
specified sex trait modification procedures and drugs.
[13.10.41.10 NMAC
- N/E, 05/05/2026]
13.10.41.11 CONFIDENTIALITY:
A. A health insurer shall maintain confidentiality of
claims and services pursuant to state and federal law, including the Domestic
Abuse Insurance Protection Act, Sections 59A-16B-1 et seq. NMSA 1978.
B. The superintendent shall treat all information
received to support requests for defrayal as confidential.
[13.10.41.11 NMAC
- N/E, 05/05/2026]
13.10.41.12 DESCRIPTION OF COVERAGE: A health insurer shall annually describe
coverage for specified sex trait modification procedures in evidence of coverage
summary.
[13.10.41.12 NMAC
- N/E, 05/05/2026]
13.10.41.13 PENALTIES: In addition to any
applicable suspension, revocation or refusal to continue any certificate of
authority or license under the Insurance Code, a penalty for any violation of
this rule may be imposed against an insurer in accordance with Sections
59A-1-18 and 59A-46-25 NMSA 1978.
[13.10.41.13 NMAC
- N/E, 05/05/2026]
13.10.41.14 SEVERABILITY: If any section of
this rule, or the applicability of any section to any person or circumstance,
is for any reason held invalid by a court of competent jurisdiction, the
remainder of the rule, or the applicability of such provisions to other persons
or circumstances, shall not be affected.
[13.10.41.14 NMAC
- N/E, 05/05/2026]
History of
13.10.41 NMAC: [RESERVED]