SB 536
Page 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
AN ACT
RELATING TO HEALTH INSURANCE; PROVIDING COVERAGE FOR MENTAL
HEALTH BENEFITS NOT COVERED BY INDIVIDUAL HEALTH INSURANCE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. Section 59A-54-12 NMSA 1978 (being Laws
1987, Chapter 154, Section 12, as amended by Laws 2005,
Chapter 301, Section 6 and by Laws 2005, Chapter 305, Section
6) is amended to read:
"59A-54-12. ELIGIBILITY--POLICY PROVISIONS.--
A. Except as provided in Subsection B of this
section, a person is eligible for a pool policy only if on
the effective date of coverage or renewal of coverage the
person is a New Mexico resident, and:
(1) is not eligible as an insured or covered
dependent for any health plan that provides coverage for
comprehensive major medical or comprehensive physician and
hospital services;
(2) is currently paying a rate for a health
plan that is higher than one hundred twenty-five percent of
the pool's standard rate;
(3) has a mental health diagnosis and has
individual health insurance coverage that does not include
coverage for mental health services;
(4) has been rejected for coverage for
pg_0002
SB 536
Page 2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
comprehensive major medical or comprehensive physician and
hospital services;
(5) is only eligible for a health plan with
a rider, waiver or restrictive provision for that particular
individual based on a specific condition;
(6) has a medical condition that is listed
on the pool's prequalifying conditions;
(7) has as of the date the individual seeks
coverage from the pool an aggregate of eighteen or more
months of creditable coverage, the most recent of which was
under a group health plan, governmental plan or church plan
as defined in Subsections P, N and D, respectively, of
Section 59A-23E-2 NMSA 1978, except, for the purposes of
aggregating creditable coverage, a period of creditable
coverage shall not be counted with respect to enrollment of
an individual for coverage under the pool if, after that
period and before the enrollment date, there was a
sixty-three-day or longer period during all of which the
individual was not covered under any creditable coverage; or
(8) is entitled to continuation coverage
pursuant to Section 59A-23E-19 NMSA 1978.
B. Notwithstanding the provisions of Subsection A
of this section:
(1) a person's eligibility for a policy
issued under the Health Insurance Alliance Act shall not
pg_0003
SB 536
Page 3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
preclude a person from remaining on or purchasing a pool
policy; provided that a self-employed person who qualifies
for an approved health plan under the Health Insurance
Alliance Act by using a dependent as the second employee may
choose a pool policy in lieu of the health plan under that
act; and
(2) if a pool policyholder becomes eligible
for any group health plan, the policyholder's pool coverage
shall not be involuntarily terminated until any preexisting
condition period imposed on the policyholder by the plan has
been exhausted.
C. Coverage under a pool policy is in excess of
and shall not duplicate coverage under any other form of
health insurance.
D. A policyholder's newborn child or newly adopted
child is automatically eligible for thirty-one consecutive
calendar days of coverage for an additional premium.
E. Except for a person eligible as provided in
Paragraph (7) of Subsection A of this section, a pool policy
may contain provisions under which coverage is excluded
during a six-month period following the effective date of
coverage as to a given individual for preexisting conditions.
F. The preexisting condition exclusions described
in Subsection E of this section shall be waived to the extent
to which similar exclusions have been satisfied under any
pg_0004
SB 536
Page 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
prior health insurance coverage that was involuntarily
terminated, if the application for pool coverage is made not
later than thirty-one days following the involuntary
termination. In that case, coverage in the pool shall be
effective from the date on which the prior coverage was
terminated. This subsection does not prohibit preexisting
conditions coverage in a pool policy that is more favorable
to the insured than that specified in this subsection.
G. An individual is not eligible for coverage by
the pool if:
(1) except as provided in Subsection I of
this section, the individual is, at the time of application,
eligible for medicare or medicaid that would provide coverage
for amounts in excess of limited policies such as dread
disease, cancer policies or hospital indemnity policies;
(2) the individual has voluntarily
terminated coverage by the pool within the past twelve months
and did not have other continuous coverage during that time,
except that this paragraph shall not apply to an applicant
who is a federally defined eligible individual;
(3) the individual is an inmate of a public
institution or is eligible for public programs for which
medical care is provided;
(4) the individual is eligible for coverage
under a group health plan;
pg_0005
SB 536
Page 5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(5) the individual has health insurance
coverage as defined in Subsection R of Section 59A-23E-2 NMSA
1978;
(6) the most recent coverages within the
coverage period described in Paragraph (7) of Subsection A of
this section were terminated as a result of nonpayment of
premium or fraud; or
(7) the individual has been offered the
option of continuation coverage under a federal COBRA
continuation provision as defined in Subsection F of Section
59A-23E-2 NMSA 1978 or under a similar state program and he
has elected the coverage and did not exhaust the continuation
coverage under the provision or program, provided, however,
that an unemployed former employee who has not exhausted
COBRA coverage shall be eligible.
H. Any person whose health insurance coverage from
a qualified state health policy with similar coverage is
terminated because of nonresidency in another state may apply
for coverage under the pool. If the coverage is applied for
within thirty-one days after that termination and if premiums
are paid for the entire coverage period, the effective date
of the coverage shall be the date of termination of the
previous coverage.
I. The board may issue a pool policy for
individuals who:
pg_0006
SB 536
Page 6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(1) are enrolled in both Part A and Part B
of medicare because of a disability; and
(2) except for the eligibility for medicare,
would otherwise be eligible for coverage pursuant to the
criteria of this section."