New Mexico

Liver damage restrictions

Fee-For-Service (FFS) does not impose any liver damage restrictions. New Mexico’s Medical Assistance Division (MAD) requires all Managed Care Organizations (MCOs) to follow FFS criteria. Two MCOs (Molina Healthcare and UnitedHealthcare (UHC)) are complying. One MCO (Presbyterian) is not complying and requires at least minimal liver damage (F1 or greater). Coverage requirements for one MCO (BlueCrossBlueShield (BCBS)) are not publicly available.

Sobriety restrictions

FFS requires patients with a history of alcohol or substance use to be referred for counseling and substance use treatment, but does not deny coverage based on such history. New Mexico also prohibited MCOs from issuing approvals or denials based on active alcohol or substance use screening. Three MCOs (Molina, Presbyterian and UHC) are complying and do not impose sobriety requirements. Coverage requirements for one MCO (BCBS) are not publicly available.

Prescriber restrictions

FFS does not impose prescriber requirements. Three MCOs (Molina, Presbyterian, and UHC) have complied and do not impose prescriber requirements. Coverage requirements for one MCO (BCBS) are not publicly available.

Recommendations

• Ensure all MCOs comply with New Mexico’s MAD’s directive regarding hepatitis C coverage requirements.
• Require transparency regarding hepatitis C coverage criteria.