New Mexico Register / Volume XXXVII,
Issue 20 / October 20, 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; N, 10/20/2026]
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; N, 10/20/2026]
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; N, 10/20/2026]
13.10.41.4 DURATION: Permanent.
[13.10.41.4 NMAC - N/E, 05/05/2026; N, 10/20/2026]
13.10.41.5 EFFECTIVE DATE: October 20,
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; N, 10/20/2026]
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; N, 10/20/2026]
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. “gender identity” means
emotional, physical, and social expression of an individual’s preferred
sex traits;
C. “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;
D. “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;
E. “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;
F. “specified sex trait modification
procedure” has the same meaning as defined in 45 C.F.R. Section 156.400;
and
G. “superintendent” has the same
meaning as defined in Section 59A-1-12 NMSA 1978.
[13.10.41.7 NMAC - N/E, 05/05/2026; N, 10/20/2026]
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; N, 10/20/2026]
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; N, 10/20/2026]
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,
consistent with criteria that the superintendent establishes, incurred during
the prior full calendar year for specified sex trait modification procedures.
D. The superintendent shall not use
federal funds for defrayal of costs associated with specified sex trait
modification procedures.
E. 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; N, 10/20/2026]
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; N, 10/20/2026]
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; N, 10/20/2026]
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; N, 10/20/2026]
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; N, 10/20/2026]
History of 13.10.41 NMAC: [RESERVED]