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HB 461

An Act providing for Commonwealth funding safety and transparency.

2025-2026 Regular Session Introduced by Heather Boyd and 17 co-sponsors

HB 461 creates a formal process for eligible providers to obtain exemptions from insurer prior authorization for certain outpatient services to reduce delays.

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Bill Summary · HB 461

Summary — HB 461: Prior Authorization Process Exemptions (New Mexico)

Status: Action postponed indefinitely (most recent action 2025-06-03)
Introduced: Nov 12, 2024 (various committee activity in 2025)
Primary subject: Health care prior authorization; insurance regulation

Purpose

HB 461 would create a formal process under New Mexico’s Prior Authorization Act allowing qualified health care professionals to obtain an exemption from an insurer’s prior authorization (PA) requirement for certain outpatient services. The goal is to reduce administrative delays when providers consistently receive approvals.

Key provisions

  • Establishes a process for providers to apply for PA exemptions for outpatient health care services. (An HHHC amendment excludes pharmaceutical services / prescription drugs from the exemption.)
  • “Evaluation periods” are six-month windows beginning each January and June. Providers may apply no sooner than 30 days after the end of an evaluation period.
  • Eligibility threshold: in the prior six-month evaluation period, at least 90% of a provider’s 10 or more PA requests for a specific outpatient service must have been approved (initially or after appeal).
  • Insurers must approve or deny exemption requests within 10 business days and must give written explanations for denials with supporting data.
  • Insurers may review and, once per evaluation period, rescind an exemption if retrospective review of a random sample (5–20 claims) shows <90% of claims would meet medical-necessity criteria; 25 days’ written notice required before rescission takes effect.
  • Immediate and retroactive rescission allowed where fraud or abusive use is found.
  • Providers may request an independent review of a rescission decision without exhausting internal appeals. Independent review must:
    • Be completed within 30 days of request.
    • Be conducted by a New Mexico-licensed medical reviewer; for physicians, a reviewer in the same/similar specialty.
    • Allow providers to request review of a different sample of claims.
    • Be paid for by the insurer (including reasonable record-copying fees).
    • Produce a binding decision; if overturned (except for fraud/abuse), insurer may not attempt rescission again until next evaluation period.
  • If independent review affirms rescission, the insurer may not retroactively deny prior authorizations granted under the exemption; provider may reapply next evaluation period.

Effective date

The bill sets an effective date of January 1, 2026.

Fiscal impact (summary)

  • Office of the Superintendent of Insurance: no significant fiscal impact expected.
  • Health Care Authority (HCA) / Medicaid: potential costs if the law applies to Medicaid:
    • Staffing: possible need for a Pharmacy Technician III (~$78.9k annually; split GF/federal).
    • Independent review costs: prior-state examples estimate ~$460 per exemption review; one estimate projects ~$218k/year if many providers apply.
    • Medicaid IT: MMIS/financial module changes estimated ~$600k (approx. $540k federal / $60k state).
  • Overall fiscal effects are partially indeterminate and depend on whether Medicaid is covered and on provider application rates.

Who would be affected

  • Health care professionals/providers performing outpatient services (potential relief from PA requirements if eligible).
  • Health insurers and managed care organizations (new application, monitoring, review, and independent-review obligations).
  • State Medicaid program, if interpreted to apply (administration, IT, and review costs).
  • Patients could benefit from faster access to services when providers qualify for exemptions.

Procedural history / current status

HB 461 received committee consideration and was amended (notably to exclude pharmaceuticals). It passed some committee stages but, as of the latest record provided, was postponed indefinitely (not enacted).

Compiled from official sources — confirm details with the bill’s official record.

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