CurrentOptumPolicy N/A

New Mexico behavioral health cost-share waiver

Defines Optum's implementation of a New Mexico mandate waiving member cost share for specified covered behavioral health services for applicable fully insured and ASO non‑ERISA members and in‑network providers, effective 1/1/2022 through 12/31/2026.

Policy Summary

PayerOptum

PolicyNew Mexico behavioral health cost-share waiver

Policy CodePolicy N/A

Change TypeNo material change

Effective Date1/1/2022

Next Review DateN/A

Key ActionVerify member eligibility and benefit type and confirm in-network status prior to appointment; continue standard claims submission — cost share will not be applied to applicable claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/1/2022effective date for waived cost share

12/31/2026mandate end date

In‑Networkprovider applicability

ASO‑ERISA/Medicaid/Medicaremember types not covered

Deductible appliesHSA-eligible plan treatment

Cost-share Waiver Criteria

Cost-share waiver criteria

Cost share (copayment, coinsurance, deductible or other member financial obligations) will be waived for covered behavioral health services for applicable members and in‑network providers, subject to the applicability rules and exclusions below.

Effective dates: Waiver applies to dates of service on or after 1/1/2022 through 12/31/2026.

Member eligibility: Member is covered by a Commercial Fully Insured or ASO - Non‑ERISA plan (through the NM Health Care Purchasing Act) sitused/issued in New Mexico, OR a New Mexico resident with such a plan sitused/issued in another state.

Provider eligibility: In‑network providers only.

Excluded members and providers: Does NOT apply to members covered by Commercial ASO‑ERISA (Administrative Services Only), Medicaid, or Medicare plans; does NOT apply to out‑of‑network providers.

Policy Summary

PayerOptum

PolicyNew Mexico behavioral health cost-share waiver

Policy CodePolicy N/A

Change TypeNo material change

Effective Date1/1/2022

Next Review DateN/A

Key ActionVerify member eligibility and benefit type and confirm in-network status prior to appointment; continue standard claims submission — cost share will not be applied to applicable claims.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered service settings and types (ONE or more of the following):

Professional services rendered by a behavioral health (BH) provider, except when delivered in an emergency room or urgent‑care center.
Services rendered by a primary care provider when a behavioral health diagnosis is the first or second code on the claim.
Outpatient facility services: outpatient services (including professional services) delivered in a BH facility, or in a non‑BH facility when the attending provider is a BH provider; non‑ER/urgent‑care outpatient services delivered in a non‑BH facility by a non‑BH provider when a BH diagnosis is first or second on the claim; includes transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT).
Inpatient facility services: inpatient services (including professional services) delivered in a BH hospital or BH department of a general acute care hospital, residential treatment center, or in a general acute care hospital when the attending provider is a BH provider; includes detoxification services and TMS/ECT.
Ancillary services: clinical laboratory, radiology and other imaging services when ordered by a BH provider, or when a BH diagnosis is first or second on the claim (including when ordering provider info is absent).

Excluded Behavioral Diagnosis Codes and Plan Details

Behavioral diagnosis codes excluded from waiverICD-10Not Covered

F01.x - F09.9x	Mental disorders due to known physiological conditions
F70.x - F79.9x	Mild intellectual disabilities
F80.x - F83.9x	Pervasive and specific developmental disorders
F85.x - F89.9x	Pervasive and specific developmental disorders
F91.x - F98.9x	Behavioral and emotional disorders with onset usually occurring in childhood and adolescence

inv-03: HSA deductible

HSA-eligible fully insured plansMember responsible for meeting deductible; once deductible met, copay/coinsurance will be waived

ScopeApplies only to Members covered by Commercial Fully Insured plans sitused/issued in NM (or NM residents with such plans sitused/issued elsewhere)

Provider applicabilityIn‑Network providers only

Excluded member typesDoes not apply to Members covered by Commercial ASO‑ERISA, Medicaid, or Medicare plans

Verification and Billing Workflow

Documentation Required

Verify eligibility, benefit type, and follow standard claims submission

Verify member eligibility and benefit type before each appointment and confirm the member is covered by a Commercial Fully Insured or ASO - Non‑ERISA plan sitused/issued in NM (or an NM resident with such a plan). Confirm the provider is in‑network. Continue to submit behavioral health claims using standard claims submission protocols; applicable claims will be paid without applying member cost share. For members with Commercial Fully Insured HSA‑eligible plans, the member is responsible for meeting their deductible; once the deductible is met, copay/coinsurance will be waived.

Verify whether the member's account is Fully Insured or ASO - Non‑ERISA vs ASO‑ERISA by contacting Customer Service using the phone number on the back of the member's ID card.
Confirm in‑network status prior to appointment; out‑of‑network providers are not covered by the waiver.
Submit claims following standard claims submission protocol — cost share will not be applied to applicable claims payments.

Behavioral Health and Plan Applicability Definitions

inv-05: BH services

DefinitionBehavioral health (BH) services include professional services rendered by a BH provider, outpatient and inpatient facility services delivered in BH settings or when the attending provider is a BH provider, ancillary services ordered by a BH provider, and TMS and ECT services

Includes primary care servicesServices rendered by a primary care provider when a BH diagnosis is the 1st or 2nd code on the claim

Ancillary servicesClinical laboratory, radiology and other imaging services when ordered by a BH provider or when a BH diagnosis is 1st or 2nd on the claim

Exclusions for settingProfessional BH services delivered in an emergency room or urgent-care center are excluded

inv-06: Plan applicability

Covered plan typesCommercial Fully Insured or ASO - Non‑ERISA plans sitused/issued in NM, or NM residents with such ASO - Non‑ERISA or Fully Insured plans

Excluded plan typesCommercial ASO‑ERISA (Administrative Services Only), Medicaid, and Medicare plans are not covered by the waiver

Provider networkApplies to In‑Network providers only; Out‑of‑Network providers are excluded