Step Therapy Protocols Must Be Established
March 20, 2018
On Feb. 28, 2018, Gov. Martinez signed SB 11 into law, which mandates certain actions in regards to step therapy protocols. As background, step therapy protocol means issuers require plan participants to use certain prescription drugs, other than prescription drugs recommended by participants’ health care providers, or to take prescription drugs in a certain order before plans provide coverage for recommended prescription drugs.
This bill requires insurers that require step therapy before providing prescription drugs to establish, implement and administer the step therapy protocol in accordance with industrywide clinical practice guidelines. Clinical review criteria must be based on clinical practice guidelines that do all of the following:
- Recommend that prescription drugs subject to step therapy protocols be taken in specific order required by step therapy protocols
- Are developed and endorsed by an interdisciplinary panel of experts that manage conflicts of interest
- Are based on high-quality studies, research and medical practice
- Are created by an explicit and transparent process that minimizes bias and conflicts of interest, explains relationships between treatment options and outcomes, rates quality of evidence used to support recommendations and considers relevant subgroups and preferences
- Consider the needs of atypical populations and diagnoses
The law also outlines when participants should be able to request step therapy exceptions and specifies that plans must provide participants with decisions those exceptions within 72 hours (or within 24 hours in emergency situations).
This law will become effective for plans delivered, issued for delivery or renewed on or after Jan. 1, 2019.
SB 11 »
NM State Updates - 2015 Jan 17 No.01
November 17, 2015
On Oct. 27, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-028, which addresses the definition of ‘small group’ in New Mexico in light of the PACE Act. As background, PPACA included a provision to change the definition of small employer from 1-50 to 1-100 employees effective Jan. 1, 2016. On Oct. 7, 2015, President Obama signed into law the PACE Act, which repeals the mandated small-group expansion from groups of up to 50 employees to groups of up to 100 employees. Thus, unless a state has expanded its definition of small employer, PPACA’s insurance mandates would not apply to employers in the 51-100 group in that state.
New Mexico insurance statutes define a “small group” as an employer with 2 to 50 employees. As allowed under the PACE Act, New Mexico will keep the definition of small group at 2 to 50 employees. Thus, groups with 51 to 100 employees will continue to be rated as large groups and will not be required to switch to the small group market in 2016.
The Office of the Superintendent of Insurance will not accept adjustments to already approved rates for 2016.
Bulletin 2015-028 »
NM State Updates - 2015 Jan 11 No.01
August 11, 2015
On July 14, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-24, which expands upon and supersedes Bulletin No. 2015-021 (see the June 16, 2015 Compliance Corner). These bulletins are in reference to the CMS bulletin issued March 5, 2014 outlining transitional policies and their options. PPACA requires states to change the definition of small group from 2-50 employees to 2-100 employees. The March 5, 2014, CMS guidance indicates that states can elect to either implement the change Jan. 1, 2016, or to renew groups of 51-100 into their existing large group policies. New Mexico has elected to allow issuers of large group policies to permit groups of 51-100 employees to purchase new large group coverage until Dec. 31, 2015, and to allow the renewal of large group coverage between Jan. 1, 2016, and Oct. 1, 2016. The renewal is available to any 51-100-sized employer who has coverage prior to Dec. 31, 2015 and can be accomplished using either the existing insurer or a new issuer.
If an insurer makes offers of renewal under this notice, the offer must be made to all of an insurer’s eligible employer groups. Plan year 2015 new or renewed polices issued under this notice shall not be in effect for more than one year. Furthermore, no plans issued under this transition policy shall extend beyond Oct. 1, 2017. Such plans must comply with PPACA requirements applicable to large group market plans. Early renewals are permissible and plans may renew for periods of less than a year if agreed upon by the insurer and the group. Finally, any such renewals must be made on or before Oct. 1, 2016.
Bulletin No. 2015-024 »
NM State Updates - 2015 Jun 16 No.01
June 16, 2015
On June 3, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-021, which supersedes Bulletin No. 2015-012 (See the May 19, 2015 Compliance Corner). The new bulletin makes a correction to the previously issued bulletin. Both bulletins are in reference to the CMS bulletin issued March 5, 2014 outlining transitional policies and their options. PPACA requires states to change the definition of small group from 2-50 employees to 2-100 employees. The March 5, 2014, CMS guidance indicates that states can elect to either implement the change Jan. 1, 2016 or to renew groups of 51-100 into their existing large group policies through Oct. 1, 2015. Bulletin No. 2015-012 incorrectly advised re-enrollment was permitted until Oct. 1, 2016. Bulletin No. 2015-021 correctly advises that large groups of 51-100 employees will be able to re-enroll into their existing policies through Oct. 1, 2015 and may renew for one year only. As of Nov. 1, 2016, all groups with between 51-100 employees must be included in the small group market. As we shared in May, New Mexico employers with between 51-100 employees should work with their insurer in determining whether re-enrollment is appropriate.
Bulletin No. 2015-021 »
NM State Updates - 2015 May 19 No.03
May 19, 2015
On April 1, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-015 repealing and replacing Bulletin No. 2014-003. Superintendent Franchini is still concerned that some individuals are not aware that limited benefit plans (excepted benefit plans) do not provide an individual with MEC, the coverage required to avoid PPACA’s individual mandate penalty. As such, this bulletin requires that issuers of group and individual hospital plans (except disability plans) notify every individual insured under such plans that the coverage does not satisfy the individual mandate’s MEC requirement.
The following disclosure should be made:
“This type of plan is NOT considered ‘minimum essential coverage’ under the Affordable Care Act and therefore does NOT satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a tax penalty. Please consult your tax advisor.”
This notice should also be provided will all policies issued or renewed on or after Jan. 1, 2014, in at least 10-point font on the cover page of the policy. While the bulletin adds no new employer compliance obligations, employers that sponsor such non-MEC plans should look for the disclosure from insurers, which may also help employees understand their obligations under the individual mandate.
Bulletin No. 2015-015 »
NM State Updates - 2015 May 19 No.02
May 19, 2015
On March 25, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-013. This bulletin relates to the provision of autism benefits in individual and small group plans. New Mexico’s autism coverage mandate, which predates PPACA, directs carriers to include autism spectrum benefits in their major medical plans. However, the mandate includes limits that, due to PPACA, are no longer allowed, and therefore no longer enforceable, in the individual or small group market. While there is an exception permitting continued limits in large plans, the bulletin reminds insurers that the MHPAEA requires many insurance plans that cover mental health or substance use disorders (including autism spectrum disorders) to offer coverage for those services that is no more restrictive than the coverage for medical/surgical conditions.
Bulletin No. 2015-013 »
NM State Updates - 2015 May 19 No.01
May 19, 2015
On March 25, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-012. This bulletin is in reference to the CMS bulletin issued on March 5, 2014 outlining transitional policies and their options. Under PPACA, states must change the definition of small group from 2-50 employees to 2-100 employees. The March 5, 2014, CMS guidance indicates that states can elect whether to implement the change on Jan. 1, 2016, or to renew groups of 51-100 into their existing large group policies through Oct. 1, 2016 (with coverage extending to Dec. 31, 2016). Under either option, all groups with 51-100 employees must be included in the small group market as of Jan. 1, 2017. According to the new bulletin, New Mexico will proceed with the second option, meaning large groups of 51-100 employees will be able to re-enroll into their existing policies through Oct. 1, 2016 and coverage for such will extend until Dec. 31, 2016. New Mexico employers that fall into 51-100 group should work with their insurer in determining whether re-enrollment is appropriate.
Bulletin No. 2015-012 »
NM State Updates - 2015 Jan 07 No.01
April 07, 2015
On March 20, 2015, Gov. Martinez signed SB 121 into law, creating the Vaccine Purchasing Act. SB 121 authorizes the Arizona Department of Health to establish a statewide program that provides critical vaccines for children against life-threatening diseases and funds the program. Health insurers and group health plans will reimburse the Department of Health for the cost of vaccines provided to their participants.
Not later than 120 days following enactment, the Office of Superintendent of Insurance is to establish rules requiring each health insurer and group health plan to annually report the number of children it insured who were under the age of nineteen as of December 31st of the prior year. When the rules are released, we will report them in Compliance Corner.
Self-insured employers will be responsible for this reporting as well as reimbursing the Department of Health. Health insurance carriers will take care of the reporting and reimbursing on behalf employers with fully-insured plans, but will presumably pass the cost on to those plans through increased rates.
An insurer or group health plan that fails to file a required report will be subject to a late filing fee of $500 per day after the due date. The office of the superintendent of insurance has the power to request records supporting the above-mentioned report and if a discrepancy is not due to a good faith mistake, then a civil penalty of $500 will be due. Late reimbursements will also result in a $500 per day penalty.
This act goes into effect immediately.
SB 121 »
NM State Updates - 2015 Jan 10 No.01
March 10, 2015
On Feb. 19, 2015, Superintendent of Insurance Franchini issued Bulletin No. 2015-006, which relates to the transparency of the cost to insureds on all health insurance forms. The bulletin requires health insurers to include information from the perspective of the insured/policyholder to be displayed on all documentation that includes cost sharing features. "Documentation" includes forms, insurance cards, and advertising materials.
Unless specifically excluded by statute, all forms should be submitted to the New Mexico Office of the Superintendent of Insurance for review.
Although the bulletin relates to a requirement for insurers, it is important for employers to understand that insurers in New Mexico are now required to do this.
Bulletin No. 2015-006 »