APPLYING COST-SHARING WAIVERS TO BEHAVIORAL HEALTH SERVICES: EFFECTIVE January 1, 2027

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE DEPUTY SUPERINTENDENT Alice T. Kane Timothy Vigil SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2026-008 April 20, 2026 TO: ALL INSURERS LICENSED TO SELL HEALTH INSURANCE IN NEW MEXICO RE: APPLYING COST-SHARING WAIVERS TO BEHAVIORAL HEALTH SERVICES: EFFECTIVE January 1, 2027 Senate Bill 120 titled “No Behavioral Health Cost Sharing,” was signed into law by Governor Michelle Lujan Grisham on April 8, 2025, effective January 1, 2026. Senate Bill 120 removes the sunset date of January 1, 2027, for behavioral health cost sharing elimination that was passed in SB317 in the 2021 legislative session and signed by the Governor on April 8, 2021. SB120 builds on SB317 which 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 law prohibits a health insurance policy, health care plan or certificate of health insurance, or health maintenance organization contract whether individual, group or blanket that is delivered, issued for delivery, or renewed in New Mexico from imposing cost sharing, including copayments, coinsurance, or deductibles, on BH services as This bulletin will take effect on January 1, 2027. Until that date, carriers must continue to follow Bulletin 2021-009. Bulletin 2021-009 will remain in effect through 12:00 a.m. December 31, 2026, and then will be considered repealed. B U L L E T I N 2 0 2 6 - 0 0 8 P a g e | 2 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us defined in NMSA 1978, Sections 59A-22-57(B)(1), 59A-23-16(B)(1), 59A-46-57(B)(1), and 59A- 47-51(B)(1). The application of the prohibition on cost-sharing for BH services must be standardized across all subject health plans effective immediately. This bulletin does not apply to catastrophic plans as defined under 42 USCA Section 18022(e) and high-deductible health plans with health savings accounts until a subscriber's deductible has been met, unless otherwise permitted by federal law. Carriers should note that the prohibition on cost sharing applies only when the primary diagnosis on the claim is a behavioral health diagnosis. Definition of Behavioral Health Services Behavioral health services are defined as professional and ancillary services for the treatment, habilitation, prevention and identification of mental illnesses, substance abuse disorders and trauma spectrum disorders, including inpatient, detoxification, residential treatment and partial hospitalization, intensive outpatient therapy, outpatient therapy and all medications, including brand-name pharmacy drugs when generics are unavailable as defined in NMSA 1978, Section 59A-22-57. To ensure consistent application across all subject health plans, the New Mexico Office of Superintendent of Insurance (OSI) issues this bulletin to provide implementation guidance. The following criteria shall be used by carriers to identify BH services that are not subject to cost sharing, organized by service type: Professional Services x Professional services rendered by a BH provider. Services rendered by a primary care provider, for the treatment of a BH condition, and when a BH diagnosis is the primary diagnosis on the claim. B U L L E T I N 2 0 2 6 - 0 0 8 P a g e | 3 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us 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. • Services, including professional services, delivered in a non-BH facility, by a non-BH provider, when a BH diagnosis is the primary diagnosis on the claim. • Transcranial magnetic stimulation treatment services and electroconvulsive therapy services, including professional services. 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 or a consulting provider is a BH provider for the treatment of a behavioral health primary diagnosis. • 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 the primary diagnosis. B U L L E T I N 2 0 2 6 - 0 0 8 P a g e | 4 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us 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. • A BH provider can prescribe medications from therapeutic categories and classes not included on the attached list, provided that the prescription is directly related to the primary diagnosis. It is up to the carrier to determine whether the drug should be treated as a BH drug for cost-sharing purposes. • Cost-sharing can 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. 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 NMSA 1978, Sections 59A-22-57, 59A-23-16, 59A-46-57, and 59A-47-51. Carriers are directed to use the presence of an ICD-10-CM “F-codes” in the primary 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 B U L L E T I N 2 0 2 6 - 0 0 8 P a g e | 5 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us • F91.x – F98.9x - Behavioral and emotional disorders with onset usually occurring in childhood and adolescence Additionally, carriers are directed to use the presence of the following 4 ICD-10-CM codes in the primary diagnosis as needed to identify a BH service • Z13.30 - Encounter for screening examination for mental health and behavioral disorders, unspecified • Z13.31 - Encounter for screening for depression • Z13.32 - Encounter for screening for maternal depression • Z13.39 - Encounter for screening examination for other mental health and behavioral disorders These directives apply to cost-sharing only. Carriers may continue to apply their plans’ drug formulary policies, prior authorization and utilization management policies, and other drug coverage policies to the extent allowed under New Mexico law. 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. OSI recognizes that carriers and reporting entities may need to make system updates or operational adjustments to comply with the requirements of this bulletin and encourages entities to begin planning for these changes. OSI expects these updates and adjustments to be completed by January 1, 2027. B U L L E T I N 2 0 2 6 - 0 0 8 P a g e | 6 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us For more information or questions, please contact monica.snowden@osi.nm.gov ISSUED this 20th day of April 2026. __________________________________ ALICE T. KANE Superintendent of Insurance ___ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ ____ __ __ __ __ __ ______ __ __ ____ __ __ ____ __ __ __ __ __ __ ____ __ __ _ __ __ __ __ ____ __ __ __ __ ____ _ __ __ ____ __ ___ LICE T. KANE 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