New Mexico Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

New Mexico Grantee: New Mexico Office of Superintendent of Insurance

Award Date: October 31, 2016

Total Award: $1,160,464.30

Baseline Award: $476,998

Selected Market Reforms Amount: $510,000

Workload Award Amount: $173,466.30

• Section 2707 - The New Mexico Office of Superintendent of Insurance will create a tool to assist in comparison of plans’ drug formulary and pricing structures that will enhance the existing policy filing review process and allow consumers to engage in more educated plan selection. The consumer focused components of this tool will assist consumers in understanding their options and coverage benefits for particular drugs, their drug costs, and will enhance consumer feedback on drug access issues. The Office of Superintendent of Insurance will conduct outreach to consumers to let them know of the tool’s availability and capabilities. The Office of Superintendent of Insurance will also contract with a pharmacist to review health plan drug formularies to ensure that health insurance issuers are not discouraging individuals with potentially high cost medical conditions from enrollment. The pharmacist-developed drug formulary review protocols will assist with the following:
  • Creating checklists for review of drug formularies for compliance with the Affordable Care Act (ACA) non-discrimination provision;
  • Ensuring health insurance issuers are meeting New Mexico’s benchmark plan standards for drug coverage categories;
  • Ensuring health insurance issuers have not engaged in discriminatory benefit design by placing generic drugs prescribed to treat chronic, potentially high-cost conditions into higher cost-sharing tiers unwarranted by actual drug cost; and
  • Ensuring health insurance issuers have not engaged in discriminatory benefit design through barriers created by medical management techniques such as step-therapy, prior authorizations, and fail-first policies.
  • The Office of Superintendent of Insurance will develop bulletins, regulations, and legislative analysis based on the findings, and engage in data calls to health insurance issuers on drug coverage and medical management policies.

• Section 2713 - The New Mexico Office of Superintendent of Insurance will contract with a pharmacist for review of plans and development of plan review protocols for administered preventive care benefits that include Federal cost-sharing free contraception, pre and post-natal preventive care measures, vaccination, and smoking cessation coverage, as well as other benefits. The Office of Superintendent of Insurance will communicate with health insurance issuers about non-compliance and violation of the ACA’s cost-sharing free preventive care measures. New Mexico will develop bulletins, regulations, and legislative analysis based on the findings of the contracted pharmacist, and engage in data calls to health insurance issuers on drug coverage and medical management policies. Finally, the Office of Superintendent of Insurance will assess plan compliance with cost sharing mandates for preventive services.

• Section 2726 - The New Mexico Office of Superintendent of Insurance will conduct a two-year project that will review the current landscape of Mental Health Parity and Addiction Equity Act (MHPAEA) compliance through Stakeholder survey and engagement and claims and billing data review. The Office of Superintendent of Insurance will develop an online survey to be administered to healthcare providers regarding their experiences with obtaining and providing mental health and substance abuse care to individuals with commercial health insurance. The survey will inquire of providers’ perceptions of parity between physical and behavioral health services. The Office of Superintendent of Insurance will conduct analyses of survey response data, including covariate analyses that assess variation in responses by provider type, provider geography, type of insurance of patients, and type of medical services. The Office of Superintendent of Insurance will use claims data to track utilization by geographic area and identify gaps in utilization and provider access. The Office of Superintendent of Insurance will also request and review data on health insurance issuers’ internal review of the medical necessity of mental health and substance abuse claims for comparison to collected claims data. Finally, the Office of Superintendent of Insurance will develop New Mexico-specific tools and protocols to evaluate mental health/substance abuse parity requirements and conduct additional evaluation to ensure compliance by New Mexico health insurance plans.