Provider Access

A. Access. If an insurer’s plan limits coverage of contraceptive services and supplies to in-network providers, the Insurer shall establish and maintain a network for these services and supplies that meets the access and adequacy standards set forth in state and federal network adequacy law. B. Limited access requirements. If an insurer’s plan network lacks a sufficient number or type of participating providers or facilities to provide a particular covered contraceptive service or supply in a timely manner appropriate for the covered person’s condition, the insurer shall allow the covered person to obtain the covered service or supply from a provider or facility within reasonable proximity of the covered person at no greater cost than if the service or supply were obtained from in-network providers and facilities. [13.10.32.9 NMAC - N, 1/1/2021] 13.10.32.10 COVERAGE FOR CONTRACEPTION WHERE A PRESCRIPTION IS NOT REQUIRED: A. If a prescription is not required for the purchase of a contraceptive, an insurer shall not charge a member for a purchase at an in-network pharmacy, and shall provide a process for the member to obtain reimbursement for an out-of-network purchase. B. An insurer’s website and evidence of coverage handbook shall clearly explain the process a covered person shall use to submit a claim for reimbursement for the purchase of non-prescription contraception drugs or devices. The reimbursement process is subject to these requirements: (1) An insurer shall allow a covered person at least 90 days from the date of purchase to submit a request for reimbursement. (2) An insurer shall reimburse a covered person within 30 days of receipt of a timely and complete reimbursement request submitted electronically, by email, or by fax, and within 45 days of receipt of a timely and complete reimbursement request submitted by U.S. mail. (a) A reimbursement request that is transmitted electronically, via email, or fax, pursuant to the insurer’s instructions, is deemed received by the insurer on the date of receipt, unless the covered person receives notice of a transmission error. (b) A request for reimbursement is complete if it contains the covered person’s name and address, their plan identification number, and a paid receipt explicitly delineating the purchased services or supplies. (c) An insurer may require a covered person to use a specific claim form for a reimbursement request.