COVERAGE REQUIREMENTS AND STANDARDIZED LANGUAGE REGARDING COMPLEX REHABILITATION TECHNOLOGY (CRT)

1 STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE DEPUTY SUPERINTENDENT Alice T. Kane Timothy Vigil BULLETIN 2026-012 TO: ALL HEALTH INSURANCE PLANS OFFERING MAJOR MEDICAL COVERAGE IN NEW MEXICO RE: COVERAGE REQUIREMENTS AND STANDARDIZED LANGUAGE REGARDING COMPLEX REHABILITATION TECHNOLOGY (CRT) During the 2023 Legislative Session, Governor Michelle Lujan Grisham signed House Bill 131 specifying medical necessity and nondiscrimination standards that provide coverage for prosthetic and orthotic devices. During the 2026 Legislative Session, the governor expanded access by signing House Bill 38 to amend Sections 59A‑16‑21.4, 59A‑22‑62, 59A‑23‑32, 59A‑46‑72, and 59A‑47‑66 NMSA 1978. Legislative testimony in support of the bill established an intent to create specific health care rights for CRTs, including power-assisted mobility devices for athletic events. The Office of Superintendent of Insurance (OSI) works to ensure that health insurance carriers clearly communicate updates to insureds about changes in health insurance rights and benefits. The purpose of the bulletin is to clarify health insurance carriers’ obligations regarding medically necessary CRT devices, including requirements for replacement. Coverage for CRT devices shall be based on an insured's specific medical, physical, functional, and environmental needs and capacities to engage in daily life and physical activity. A health insurance carrier shall cover medically necessary services and supplies for CRT devices that meet each insured’s mobility needs. “CRT device” includes manual and power wheelchairs and mobility devices, including seating and positioning equipment and accessories, designed, manufactured, configured, adjusted, or modified for a specific insured to meet that insured’s unique medical, physical, functional, and environmental needs. Among these important physical needs is participation in athletic events, 2 which promotes positive social and health outcomes for all New Mexicans. CRTs are generally not useful to an insured without a disability, illness, injury, or other medical condition. This coverage includes: ● Fitting and customizing the device; ● Fabricating the device, as well as providing related materials and components; ● Programming, configuring adjusting, and aligning services for the device; ● Instructing the insured how to safely and effectively use the device; ● Repairing and replacing the device; and ● Generally covering up to two CRT devices. A health insurance carrier may cover clinical evaluations and related clinical care under either the CRT device benefit or the rehabilitative care benefit. After three years, an insured may qualify for an additional device if the provider, in consultation with the health insurance carrier, determines that it is medically necessary due to: ● Repairs that cost more than 60% of the cost of replacing the same device; or ● Documented physiological changes, such as significant weight gain or loss, a change in medical condition, or changes in mobility needs that render the current device unsuitable. Network adequacy requirements guarantee the insured access to two qualified providers in New Mexico. If two are not available to the insured, the health insurance carrier shall refer the insured to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed-upon rate. The insured is responsible only for the in-network cost sharing. A health insurance carrier shall not charge more than the inpatient medical/surgical cost-sharing for CRT devices. A health insurance carrier shall continue to charge similar cost-sharing for all other durable medical equipment cost-sharing as in previous years. ---------------------------------------------------------------------------------------------------------- Health Insurance Carriers shall communicate the language below in all Explanations of Coverage. “Coverage of Complex Rehabilitation Technology (CRT) Devices Coverage for medically necessary CRT devices is available to assist with meeting your medical, physical, functional, and environmental needs and capacities to engage in daily life and physical activity, including athletic events. We provide coverage in a nondiscriminatory manner, and you will not be limited or denied because of a disability or mobility limitation. 3 Coverage requirements: ● We will ensure you have access to a licensed physical therapist or occupational therapist, who has no financial relationship with the supplier, who can perform a clinical evaluation to determine or confirm that the device is medically necessary; and ● We will ensure you have access to a CRT device supplier that employs an assistive technology professional certified by the Rehabilitation Engineering and Assistive Technology Society of North America, who is directly involved in selecting and configuring the device. Coverage includes: ● Fitting and customizing the device; ● Fabricating the device, as well as providing related materials and components; ● Programming, configuring, adjusting, and aligning the device; ● Instructing you how to safely and effectively use the device; ● Repairing and replacing the device; and ● Generally covering up to two CRT devices. We may cover clinical evaluations and related clinical care under either the CRT device benefit or the rehabilitative care benefit. After three years, you may qualify for an additional device if your provider, in consultation with us, determines that it is medically necessary due to: ● Repairs that cost more than 60% of the cost of replacing the same device; or ● You experienced documented physiological changes, such as significant weight gain or loss, change in medical condition, or changes in mobility needs that render the current device unsuitable. Network adequacy requirements guarantee you access to two qualified providers in New Mexico. If two are not available, we will refer you to an out-of-network provider and will fully reimburse the out-of-network provider at a mutually agreed upon rate. You will only be responsible for the in-network cost sharing, which will be no more restrictive or greater than the inpatient medical/surgical cost sharing for CRT devices.” For more information or questions about this bulletin, please contact life.health@osi.nm.gov. SUPERINTENDENT OF INSRUANCE _______________________________ Alice T. Kane