COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMY

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE INTERIM SUPERINTENDENT OF INSURANCE Jennifer A. Catechis Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2023-008 APRIL 20, 2023 TO: ALL MAJOR MEDICAL HEALTH PLANS SUBJECT TO THE JURISDICTION OF THE OFFICE OF SUPERINTENDENT OF INSURANCE RE: COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMY THIS BULLETIN is issued pursuant to NMSA 1978, § 59A-2-8 and 13.1.2 NMAC. This Bulletin replaces Bulletin No. 2000-008, which is hereby rescinded and withdrawn. This Bulletin is issued by the New Mexico Office of Superintendent of Insurance (OSI) to remind managed health care plans and health insurers offering major medical plans in New Mexico about the requirements of the Women's Health and Cancer Rights Act of 1998 (WHCRA), a federal law that, in New Mexico, adds to the basic benefits required by state law. The WHCRA applies to health insurers and managed health care plans offering major medical insurance in the individual, small and large group markets. (For the limited purposes of this Bulletin, the term “major medical plan” shall refer only to those types of insurance that are within the scope of the WHCRA.) Please refer also to 13.10.29.7(M)(1)-(2) NMAC for applicable definitions. Under the WHCRA, a major medical plan that provides medical and surgical benefits for mastectomies shall also provide coverage, based on a determination of the attending physician and patient, for: B U L L E T I N 2 0 2 3 - 0 0 8 P a g e | 2 Main Office: 1120 Paseo de Peralta, Fourth Floor, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us • All stages of reconstruction of the breast on which the mastectomy has been performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of all stages of the mastectomy, including lymphedema. A major medical plan shall not deny eligibility, continued eligibility, or renewal of coverage to avoid the WHCRA’s requirements. Further, they shall not penalize or limit provider reimbursement or provide an incentive to a provider to induce the provider not to provide the care listed above. The OSI directs all managed health care plans and health insurers offering major medical plans in New Mexico to comply with federal law. Failure to comply with the WHCRA and the directives contained in this Bulletin may result in monetary penalties, suspension, revocation, or denial of a license or certificate of authority, and will result in denial of approval of any related insurance filings that are under review. If you have any questions, please contact Viara Ianakieva, Viara.Ianakieva@osi.nm.gov. ISSUED this 20th day of April, 2023. __________________________________ JENNIFER A. CATECHIS Interim Superintendent of Insurance