SENATE BILL 317: APPLYING COST-SHARING WAIVERS TO BEHAVIORAL HEALTH SERVICES

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal DEPUTY SUPERINTENDENT Jennifer A. Catechis Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2021-009 June 14, 2021 TO: ALL INSURERS LICENSED TO SELL HEALTH INSURANCE IN NEW MEXICO RE: SENATE BILL 317: APPLYING COST-SHARING WAIVERS TO BEHAVIORAL HEALTH SERVICES Senate Bill 317, titled “No Behavioral Health Cost Sharing”, was signed into law by Governor Michelle Lujan Grisham on April 8, 2021, will become effective January 1, 2022 and is scheduled to expire on December 31, 2026. Among other advancements, SB317 prohibits cost sharing, including imposition of a deductible, for behavioral health (“BH”) services covered by any health care plan “delivered, issued for delivery or renewed in New Mexico”. To ensure that all New Mexicans receive equal treatment with respect to health plan coverage for BH services, the application of the prohibition on cost-sharing for BH services must be standardized across all subject health plans on January 1, 2022. To that end, the New Mexico Office of Superintendent of Insurance (“OSI”) directs every subject health plan to use the following criteria to identify BH services that are not subject to cost sharing, listed by service type. Professional Services • Professional services rendered by a BH provider, except when delivered in an emergency room or urgent-care center. • Services rendered by a primary care provider when a BH diagnosis is the 1st or 2nd code on the claim (see definition of BH diagnoses below.) Outpatient Facility Services • Outpatient services, including professional services, delivered in a BH facility. • Outpatient services, including professional services, delivered in a non-BH facility if the attending provider is a BH provider. • Non-emergency room and non-urgent care center outpatient services, including professional services, delivered in a non-BH facility, by a non-BH provider, when a BH diagnosis is the 1st or 2nd code on the claim. • Transcranial magnetic stimulation treatment services and electroconvulsive therapy services, including professional services. B U L L E T I N 2 0 2 1 - 0 0 9 P a g e | 2 Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us Inpatient Facility Services • Inpatient services, including professional services, delivered in a BH hospital or in the BH department of a general acute care hospital. • Inpatient services, including professional services, delivered in a residential treatment center. • Inpatient services, including professional services, delivered in a general, acute care hospital when the attending provider is a BH provider. • Detoxification services, including professional services, delivered in a BH hospital, a general acute care hospital, or a residential treatment center. • Transcranial magnetic stimulation treatment services and electroconvulsive therapy services, including professional services. Ancillary Services • Clinical laboratory services, radiology services and other imaging services when the ordering provider is a BH provider. • Clinical laboratory services, radiology services and other imaging services when the ordering provider is not a BH provider, or when the ordering provider information is not present on the claim, but a BH diagnosis code is 1st or 2nd on the claim. Prescription Drugs • A prescription drug covered on the plan’s drug formulary or authorized by the plan when the drug is in a USP therapeutic category and class combination as specified on the attached list. While examples of drugs in a class are provided, the lists are not all inclusive and the carrier shall ensure its Pharmacy Benefits Manager is able to identify all drugs included in the listed categories and class combinations. • Special considerations apply for the off-label use of drugs for the treatment of BH conditions. To that end, the attached list includes some non-BH USP therapeutic categories and classes of drugs that might be used off-label for BH conditions. If the prescriber is a BH provider, the drug is to be considered a BH drug. o A BH provider might prescribe drugs from other therapeutic categories and classes that are not on the attached list. It is up to the carrier to determine whether the drug should be treated as a BH drug for cost-sharing purposes. o Cost-sharing may be applied to these non-BH drugs if the prescriber is not a BH provider. However, at least monthly, a carrier shall analyze utilization of these drugs to identify members who likely filled these prescriptions for treatment of a BH condition. When confirmed with the prescriber, carriers will reimburse these identified members their cost-sharing expenditures for these drugs and take appropriate steps to remove the cost sharing requirement for the member when prescriptions for the specified drug(s) are filled in the future. B U L L E T I N 2 0 2 1 - 0 0 9 P a g e | 3 Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us These directives apply to cost-sharing policies. Carriers may continue to apply their plans’ drug formulary policies, prior authorization and utilization management policies, and other drug coverage policies. For example, if a carrier’s formulary covers the generic version of a brand drug, there is nothing in the bill or in this guidance that would require the carrier to pay for the brand name product. If a member receives BH services subject to this guidance from an out-of-network provider, the plan may impose cost-sharing for those services unless: 1. Reimbursement for the service is governed by the Surprise Billing Act; or 2. The plan specifically authorized the out-of-network provider to deliver the service(s). If a plan is required to reimburse a member for cost sharing pursuant to this guidance, the plan may recoup the reimbursement amount from the contracted provider that accepted the cost sharing from the member, if authorized under the terms of the provider agreement. BH Diagnosis Codes The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) contains a set of diagnosis codes that begin with “F” that includes behavioral health conditions subject to SB317. Carriers are directed to use the presence of an ICD-10-CM “F-code” in the 1st or 2nd diagnosis as needed to identify a BH service, except for the following code sets: • 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 The OSI will, at times, reevaluate these directives based on carrier and other stakeholder input and on claims data. As always, OSI thanks carriers for their partnership and cooperation. ISSUED this 14th day of June, 2021. __________________________________ RUSSELL TOAL Superintendent of Insurance STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE Behavioral Health Prescription Medications Not Subject to Cost-Sharing U.S. Pharmacopeia (USP) Therapeutic Category U.S. Pharmacopeia (USP) Class (Carriers must cross-reference to their comparable therapeutic classes) EXAMPLES OF MEDICATIONS IN THE CLASS (Not intended to be all-inclusive) Anti-addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Acamprosate Calcium, Disulfiram, Naltrexone, Naltrexone Hydrochloride Opioid Dependence Buprenorphine, Buprenorphine/Naloxone Hydrochloride, Lofexidine, Naltrexone Opioid Reversal Agents Naloxone Hydrochloride Smoking Cessation Agents Bupropion Hydrochloride, Nicotine Polacrilex, Varenicline Tartrate Anticonvulsants Gamma-aminobutyric Acid (GABA) Augmenting Agents Gabapentin, Pregabalin Sodium Channel Agents Carbamazepine, Oxcarbazepine Anticonvulsants, Other Divalproex sodium, Lamotrigine, Topiramate, Valproic Acid Antidepressants Monoamine Oxidase Inhibitors Isocarboxazid, Phenelzine Sulfate, Selegiline, Tranylcypromine Sulfate SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Citalopram Hydrobromide, Desvenlafaxine, Duloxetine Hydrochloride, Escitalopram Oxalate, Fluoxetine Hydrochloride, Fluvoxamine Maleate, Nefazodone Hydrochloride, Paroxetine Hydrochloride, Sertraline Hydrochloride, Trazodone Hydrochloride, Venlafaxine Hydrochloride Tricyclics Amitriptyline Hydrochloride, Amoxapine, Clomipramine Hydrochloride, Desipramine Hydrochloride, Doxepin Hydrochloride, Imipramine Hydrochloride, Imipramine Pamoate, Nortriptyline Hydrochloride, Protriptyline Hydrochloride Trimipramine Maleate Antidepressants, Other Maprotiline Hydrochloride, Bupropion Hydrobromide, Bupropion Hydrochloride, Mirtazapine, STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE Behavioral Health Prescription Medications Not Subject to Cost-Sharing U.S. Pharmacopeia (USP) Therapeutic Category U.S. Pharmacopeia (USP) Class (Carriers must cross-reference to their comparable therapeutic classes) EXAMPLES OF MEDICATIONS IN THE CLASS (Not intended to be all-inclusive) Aripiprazole, Quetiapine Fumarate, Esketamine Hydrochloride, Chlordiazepoxide/ Amitriptyline Hydrochloride, Olanzapine/ Fluoxetine, Perphenazine/ Amitriptyline Hydrochloride Antiparkinson Agents Anticholinergics Benztropine Mesylate, Diphenhydramine Hydrochloride, Trihexyphenidyl Hydrochloride Dopamine Agonists Pramipexole Dihydrochloride (for augmentation in severe depression) Antipsychotics 1st Generation/Typical1 Chlorpromazine, Fluphenazine, Haloperidol, Loxapine, Perphenazine, Pimozide, Prochlorperazine, Thioridazine, Thiothixene, Trifluoperazine 2nd Generation/Atypical2 Aripiprazole, Asenapine, Brexpiprazole, Cariprazine Hydrochloride, Iloperidone, Lurasidone Hydrochloride, Olanzapine, Pimavanserin Tartrate, Quetiapine Fumarate, Paliperidone, Risperidone, Ziprasidone Treatment-Resistant Clozapine Anxiolytics SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Duloxetine Hydrochloride, Escitalopram Oxalate, Paroxetine Hydrochloride, Sertraline Hydrochloride, Venlafaxine Hydrochloride Benzodiazepines Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate Dipotassium, Diazepam, Midazolam, Lorazepam, Oxazepam Anxiolytics, Other Buspirone Hydrochloride, Doxepin Hydrochloride, Hydroxyzine Hydrochloride, Hydroxyzine Pamoate, Meprobamate 1 Includes long-acting injectables 2 Includes long-acting injectables STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE Behavioral Health Prescription Medications Not Subject to Cost-Sharing U.S. Pharmacopeia (USP) Therapeutic Category U.S. Pharmacopeia (USP) Class (Carriers must cross-reference to their comparable therapeutic classes) EXAMPLES OF MEDICATIONS IN THE CLASS (Not intended to be all-inclusive) Bipolar Agents Mood Stabilizers Carbamazepine, Divalproex Sodium, Lamotrigine, Lithium Carbonate, Lithium Citrate Bipolar Agents, Other Aripiprazole, Asenapine, Lurasidone, Olanzapine, Olanzapine Pamoate, Quetiapine Fumarate, Risperidone, Ziprasidone Hydrochloride Cardiovascular Agents Alpha-adrenergic Blocking Agents Prazosin Hydrochloride (for treatment of PTSD) Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines Amphetamine, Dextroamphetamine Sulfate, Dextroamphetamine Saccharate/ Amphetamine Aspartate/ Dextroamphetamine Sulfate/ Amphetamine Sulfate, Lisdexamfetamine Dimesylate, Methamphetamine Hydrochloride Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines Atomoxetine Hydrochloride, Clonidine Hydrochloride, Dexmethylphenidate Hydrochloride, Guanfacine Hydrochloride, Methylphenidate Hydrochloride Central Nervous System Agents, Other Valbenazine, Deutetrabenazine Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) Not applicable – no class assigned by USP Liothyronine (for augmentation in severe depression) Sleep Disorder Agents Sleep Promoting Agents Eszopiclone, Zolpidem (IR, ER, CR), Suvorexant, Zaleplon, Estazolam, Flurazepam, Quazepam, Temazepam, Triazolam