What the proposed rule would require · proposed October 20, 2026 · not in effect
Who the fund would pay, and for what
What the proposed 7.35.4 NMAC would require of a patient seeking help from the treatment equity fund, of a provider who bills the fund, and of the department, each requirement cited to its subsection and to the page of the proposed text. The rule is proposed, not adopted; nothing here is in effect until the department adopts it after the November 20, 2026 hearing, and the adopted text may differ. Where the proposed text departs from what the Advisory Board voted on September 11, the comparison is on The board recommendation.
Created October 22, 2026, from the text the department published October 20, 2026.
How to read this page
New from the department marks a requirement that is in the proposed text but in neither the committee's August 18 framework nor the board's September 11 vote, and that was not found in the automatic captions of the 23 recorded committee and board meetings from December 5, 2025 to September 14, 2026, searched for its terms on October 22, 2026. A caption search can miss a passage, so the mark means not found, not proven absent. The full list, item by item, is on The board recommendation.
1. For a patient
WHOA qualified patient may be deemed eligible if the patient is enrolled in the medical psilocybin program, is a New Mexico resident, has household income that does not exceed 200 percent of the federal poverty guidelines, and money is available in the fund and appropriated for the purpose. 7.35.4.8 (A), p. 1. Household means the individuals included in the patient's household for federal tax purposes for the applicable year. proposed 7.35.2.7 (H)(7), p. 3
HOW MUCHThe fund may cover up to 100 percent of the allowable amount. Eligibility "does not create entitlement to payment and does not guarantee that funding will be available for all requested treatment." 7.35.4.8 (B) and (C), p. 1
HOW LONGEligibility runs from the date of approval and ends automatically when the patient's program enrollment expires or is suspended, revoked, or withdrawn; when the patient stops being a New Mexico resident; when the department finds the determination rested on materially inaccurate or fraudulent information; when funding is exhausted or unavailable; or 12 months after funding approval. 7.35.4.8 (D), p. 1 New from the department
APPLYThrough the department's electronic system, with the patient's name and program identification number, residential and mailing addresses, proof of residency, proof of income, an authorization for the department to verify eligibility, an attestation that the information is true and complete, and anything further reasonably necessary. 7.35.4.9 (A) and (B), p. 2
RESIDENCYOne of three: a current New Mexico identification card or driver's license; "a letter of accommodation from a licensed medical or behavioral health provider attesting that the patient is a resident of New Mexico"; or a current identification card from a Native American tribe, pueblo, or nation in New Mexico together with a utility bill or other proof of residence. 7.35.4.9 (B)(3), p. 2 New from the department
INCOMEThe most recent federal tax return, or a letter from the administering agency showing current enrollment in New Mexico Medicaid, SNAP, TANF, WIC, or SSI. 7.35.4.9 (C), p. 2
SESSIONSUp to three administration sessions: the first with a combined total of six preparatory and integrative sessions, the second and the third with a combined total of two each, ten in all. 7.35.4.14 (A), pp. 3 to 4
TRAVELPaid when the shortest reasonable one-way distance from the patient's residence to the appointment, healing center, or other approved location exceeds 100 miles: mileage for a private vehicle, the actual cost of the least costly reasonable public or commercial transportation, and lodging, none above the state's maximum rates for public officers and employees. Meals, entertainment, upgrades, and personal expenses are excluded. 7.35.4.14 (B) and (E), p. 4
NO BILLA provider who accepts payment from the fund accepts the allowable amount as payment in full and may not bill the patient for the difference between its charge and what the fund paid. 7.35.4.11 (D), p. 3
REVIEWA patient may ask for administrative review of a denial, reduction, suspension, or overpayment determination within 30 calendar days of the notice, in writing through the electronic system. Review is of documents, not a hearing; the director's decision is the department's final decision; and a determination based solely on the lack of funding is not reviewable. 7.35.4.20 (A) to (C) and (H), pp. 6 to 7 New from the department
The rule does not state how long the department has to decide an application. It names the patient as eligible for travel reimbursement but defines a claimant as a certifying clinician, practitioner, healing center, producer, or other vendor (7.35.2.7 (C)(7) as proposed, amendment p. 1), and it does not state how a patient's own travel expense reaches the fund. It does not name the diagnostic evaluation, or the medication, among the expenses in 7.35.4.14 (A); a psilocybin product is reached in 7.35.4.11 (C) and 7.35.4.12 (B)(7). These are questions to put to the department.
2. For a provider who bills the fund
WHOCertifying clinicians, practitioners, producers, healing centers, and other authorized claimants, through the department's electronic system. 7.35.4.12 (A), p. 3
FIRSTBefore billing the fund, a reasonable and documented effort to obtain payment from every other payer that may be legally responsible, with an attestation and proof of denial: a denial notice, an explanation of benefits, a remittance advice, documentation that the service is categorically excluded, or other documentation the department accepts. The third parties named are "private insurance, Medicaid, Medicare, and other sources of funding." A claim to a payer is not required where the department has documented that the category of service is excluded from that payer's coverage. 7.35.4.10 (A), (B), and (D), p. 2
AMOUNTThe lesser of the claimant's usual and customary charge, the amount left after another payer, or the applicable New Mexico Medicaid or Medicare rate. Where no rate applies, the department may use the most analogous one; for a psilocybin product with no analogous rate, the department sets a uniform fee schedule based on documented acquisition cost. 7.35.4.11 (A) to (C), pp. 2 to 3 New from the department
CLAIMLegal name, address, tax identification number, and SHARE vendor number; the department certification or permit number; the patient's program number; date, location, and type of each service; billing code and service unit, named as preparation, administration, or integration session; who furnished each service; for a product, its unique identification number, quantity, and acquisition charge; other-payer documentation; travel receipts at the state mileage rate; the amount requested; and an attestation. Direct payment requires a federal form W-9 and SHARE enrollment. 7.35.4.12 (B) and (C), p. 3
180 DAYSA claim is due within 180 calendar days after the date of service; the department may extend that for good cause. The same service unit may not be billed twice. 7.35.4.12 (D) and (E), p. 3 New from the department
30 DAYSIf another payer pays after the fund has, the claimant notifies the department within 30 calendar days and returns the overpayment. 7.35.4.10 (E), p. 2 New from the department
RECORDSEvery record supporting a claim kept at least seven years after payment or the final resolution of an audit, investigation, or recovery, whichever is later, and produced within 10 business days of a request. 7.35.4.15 (A), p. 4; 7.35.4.16 (D), p. 5 New from the department
AUDITThe department may conduct prepayment reviews and post-payment, random, and risk-based audits; compare claims with licensing, tax, and Medicaid records to the extent the law permits; interview claimants and patients; review remotely or on site during business hours; and refer suspected fraud or misconduct. 7.35.4.16 (A) and (C), pp. 4 to 5
HOLDThe department may deny a claim or suspend payment on eight grounds, among them missing documentation, a duplicate or inconsistent claim, a credible allegation of fraud, a lapsed license or permit, an unpaid overpayment, and unavailable funds. Written notice comes first unless immediate action is needed to protect patients or public funds, or funding is exhausted. A suspension based solely on fund availability is not a finding of a violation. 7.35.4.17, p. 5
REPAYAn overpayment is repaid within 30 calendar days of the notice unless the department approves a repayment agreement, and may be offset against future payments. 7.35.4.18 (C) and (D), p. 6 New from the department
REVIEWThe same administrative review as a patient: 30 calendar days to request it, a recommended decision within 10 business days, the director's final decision within 10 business days of that. A request does not stay a denial, suspension, or recovery. 7.35.4.20 (B), (E) to (G), pp. 6 to 7 New from the department
3. What the department would do
Issue each payment through SHARE with the claim number, the claimant, and the amount, and keep an internal record of every application, authorization, claim, payment, denial, adjustment, hold, suspension, overpayment, and recovery, so that duplicate billing and the money remaining can be tracked. 7.35.4.13, p. 3
Evaluate periodically whether the money is distributed equitably across New Mexico, considering income, county and region, rural, frontier, and tribal access, qualifying condition, what was requested and paid, approval and denial rates, waiting times, and distance traveled; publish only aggregated or de-identified information; and use the results to improve outreach, allocation methods, and application assistance. 7.35.4.19, p. 6
4. What the proposed rule does not state
No dollar amount, per patient or in total. No time within which an application is decided. No order of priority among eligible patients when money runs short, and no apportionment by region or condition; 7.35.4.19 provides for monitoring, not allocation. No effective date: 7.35.4.5 reads "xx/xx/2026". 7.35.4.5, p. 1; 7.35.4.19, p. 6
Provenance: the source document and this page’s revisions▸
The document this page is read from
October 20, 2026
The proposed rule, 7.35.4 NMACCurrent state of truth
The proposed rule, published by the department on October 20, 2026: twenty sections setting patient eligibility for the medical psilocybin treatment equity fund, the application, reimbursement and claims, allowable expenses and travel, records, audits, payment denial and suspension, overpayments, program monitoring, and administrative review. It is the first published text of this Part, and it is proposed, not in effect; the rule hearing is November 20, 2026.
This document supersedes 0 earlier ones. Each of them, what it is, what superseded it and when, and a download, is in the register at Meetings and filings.
Revisions to this page
- October 22, 2026 The New from the department mark on each requirement in neither recommendation and not found in the recorded meetings, with a key at the top of the page.
- October 22, 2026 Created: what the proposed rule would require of a patient, of a provider who bills the fund, and of the department, each cited to its subsection and page, with what the rule does not state.