NEW MEXICO

---

The New Mexico SBL became effective January 1, 2020. New Mexico Statutes Annotated Section 59A-57A-1, et. seq 1978 and 13.10.16 and 13.10.33 NMAC. The relevant provisions of the New Mexico law include:

• A standard of reimbursement at the 60th percentile of “the allowed commercial reimbursement rate” in the geographic area in the 2017 plan year as per a third-party benchmarking database approved by the state.
• A requirement that no reimbursement can be below 150% of the 2017 Medicare rate.
• There is an arbitration process with a 90-day timeline. 13.10.16 NMAC.

According to CMS,

New Mexico does not have an applicable All-Payer Model Agreement that would determine the [OON] rate. Based on the survey response and CMS communications with New Mexico Office of Superintendent of Insurance staff, CMS understands that Section 59A-57A-1, et. seq. NMSA 1978 and 13.10.33 NMAC are specified state laws that will apply for purposes of determining the [OON] rate with respect to emergency care provided by nonparticipating providers and nonemergency health care services furnished by a nonparticipating provider at a participating facility where the participating provider is unavailable, a nonparticipating provider furnishes unforeseen services, or a nonparticipating provider renders services for which the covered person has not given specific consent for that nonparticipating provider to furnish the services furnished to individuals in group health coverage governed by the provisions of the Health Care Purchasing Act; individual health insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 22 NMSA 1978; multiple-employer welfare arrangements; group and blanket health insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 23 NMSA 1978; individual and group health maintenance organization contracts governed by the provisions of the Health Maintenance Organization Law; and individual and group nonprofit health benefits plans governed by the provisions of the Nonprofit Health Care Plan Law in New Mexico. The federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the PHS Act and 45 CFR 149.510 and 149.520 will apply for purposes of determining the [OON] rate with respect to any items and services and nonparticipating providers, nonparticipating emergency facilities, and nonparticipating providers of air ambulance services to which Section 59A-57-4(B)(3)(d) NMSA 1978 and 13.10.33 NMAC do not apply. The Office of the Superintendent of Insurance will enforce the outcome of the independent dispute resolution process for such cases in New Mexico, regardless of whether the state or federal process applies.

Letter from CMS to Governor of New Mexico, dated December 22, 2022.