CurrentOptumPolicy NM 2021000 S 317

Elimination of Cost Sharing for Behavioral Health Services and Creation of Health Care Affordability Fund

State statute establishing elimination of cost sharing for behavioral health services in applicable New Mexico health plans through January 1, 2027, and creation of a Health Care Affordability Fund funded by portions of the health insurance premium surtax to reduce premiums and cost sharing for residents and small businesses.

Policy Summary

PayerOptum

PolicyElimination of Cost Sharing for Behavioral Health Services and Creation of Health Care Affordability Fund

Policy CodePolicy NM 2021000 S 317

Change TypeStatutory enactment with funding and coverage changes

Effective DateJan 1, 2022

Next Review Date

Key ActionUntil January 1, 2027, plans delivered, issued or renewed in New Mexico that offer behavioral health services must not impose cost sharing for those services.

SourceLink

POLICY UPDATE CHANGES

Creates a Health Care Affordability Fund funded by specified portions of the health insurance premium surtax.

Prohibits cost sharing for behavioral health services in specified health plans until January 1, 2027.

Amends health insurance premium surtax rates and establishes reduction mechanics if a federal annual fee is imposed.

Requires annual reporting on fund performance and the effects of elimination of behavioral health cost sharing.

2027-01-01cost sharing elimination expires

52%→55%→30%surtax distribution schedule

Statutory Coverage and Operational Criteria

Statutory coverage and operational criteria

Coverage stance and operational criteria derived from statute:

Plans delivered, issued, or renewed in New Mexico that offer behavioral health services must not impose cost sharing (copayments, coinsurance, deductibles or other enrollee financial obligations) for those services until 2027-01-01.

Behavioral health services include professional and ancillary services for treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders, including inpatient, detoxification, residential treatment, partial hospitalization, intensive outpatient therapy, outpatient services and all medications (including brand‑name drugs when generics are unavailable).

'Cost sharing' means a copayment, coinsurance, deductible or any other form of financial obligation of the enrollee other than a premium (or share of a premium), as defined by the terms of the policy or plan.

The office of the superintendent of insurance and the legislative finance committee must report annually by November 1 on the effects of the elimination of cost sharing, using nationally recognized performance measurement tools to assess impacts on providers, patients, costs and health and social outcomes.

Behavioral Health Services, Eligibility, and Codes

Behavioral health services (services included)mixed

behavioral health services

professional and ancillary services for the treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders, including inpatient, detoxification, residential treatment and partial hospitalization, intensive outpatient therapy, outpatient and all medications, including brand-name pharmacy drugs when generics are unavailable

Income eligibility for affordability assistance

Eligible populationNew Mexico residents who qualify for advanced premium tax credits under the federal ACA

Priority for assistanceIncome eligibility parameters prioritize residents with incomes under 200% of the federal poverty level

Application timingIncome eligibility parameters to be established for plan year 2023 and each subsequent calendar year based on available funds

Program scopeEnhanced premium and cost-sharing assistance for purchase of qualified health plans on the New Mexico health insurance exchange

Extension planningSuperintendent to develop plan for extending coverage to uninsured residents who do not qualify for federal premium assistance, with submission by June 30, 2022 for possible coverage beginning July 1, 2023

Elimination of Cost Sharing — Provider Impact

Billing Rule

No cost sharing for behavioral health services through 2026

Until January 1, 2027, health plans delivered, issued for delivery, or renewed in New Mexico that offer coverage of behavioral health services must not impose cost sharing — including copayments, coinsurance, deductibles, or any other form of financial obligation other than a premium — for those behavioral health services.

Applies to group health coverage, individual and group health insurance policies, health care plans, certificates of health insurance, HMOs and nonprofit health care plans delivered, issued or renewed in New Mexico.
Cost sharing defined to include copayment, coinsurance, deductible or any other form of financial obligation of the insured/enrollee other than a premium.
Behavioral health services include professional and ancillary services for treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders, e.g., inpatient, detoxification, residential, partial hospitalization, intensive outpatient, outpatient and all medications (including brand-name drugs when generics are unavailable).

Key Definitions

Behavioral health services

Definition (term)'Behavioral health services' means professional and ancillary services for treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders

Settings includedInpatient, detoxification, residential treatment, partial hospitalization

Outpatient servicesIntensive outpatient therapy and outpatient services

MedicationsAll medications, including brand‑name pharmacy drugs when generics are unavailable

Cost sharing (defined)

Core definition'Cost sharing' means a copayment, coinsurance, deductible or any other form of financial obligation of an enrollee/insured/subscriber other than a premium or a share of a premium