0001| AN ACT | 0002| RELATING TO INSURANCE; PERMITTING PERSONS WITH A DISABILITY TO | 0003| ACQUIRE MEDICARE SUPPLEMENT HEALTH INSURANCE UNDER CERTAIN | 0004| CIRCUMSTANCES. | 0005| | 0006| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0007| Section 1. Section 59A-54-3 NMSA 1978 (being Laws 1987, Chapter 154, Section 3, as | 0008| amended) is amended to read: | 0009| "59A-54-3. DEFINITIONS.--As used in the Comprehensive Health Insurance Pool Act: | 0010| A. "board" means the board of directors of the pool; | 0011| B. "health care facility" means any entity providing health care services that is | 0012| licensed by the department of health; | 0013| C. "health care services" means any services or products included in the | 0014| furnishing to any individual of medical care or hospitalization or incidental to the furnishing of | 0015| such care or hospitalization, as well as the furnishing to any person of any other services or | 0016| products for the purpose of preventing, alleviating, curing or healing human illness or injury; | 0017| D. "health insurance" means any hospital and medical expense-incurred policy, | 0018| nonprofit health care service plan contract, health maintenance organization subscriber contract, | 0019| short-term, accident, fixed indemnity, specified disease policy or disability income contracts and | 0020| limited benefit or credit insurance, or as defined by Section 59A-7-3 NMSA 1978. "Health | 0021| insurance" does not include insurance arising out of the Workers' Compensation Act or similar | 0022| law, automobile medical payment insurance or insurance under which benefits are payable with | 0023| or without regard to fault and which is required by law to be contained in any liability insurance | 0024| policy; | 0025| E. "health maintenance organization" means any person who provides, at a | 0001| minimum, either directly or through contractual or other arrangements with others, basic health | 0002| care services to enrollees on a fixed prepayment basis and who is responsible for the availability, | 0003| accessibility and quality of the health care services provided or arranged, or as defined by | 0004| Subsection M of Section 59A-46-2 NMSA 1978; | 0005| F. "health plan" means any arrangement by which persons, including dependents | 0006| or spouses, covered or making application to be covered under the pool have access to hospital | 0007| and medical benefits or reimbursement, including group or individual insurance or subscriber | 0008| contract; coverage through health maintenance organizations, preferred provider organizations or | 0009| other alternate delivery systems; coverage under prepayment, group practice or individual | 0010| practice plans; coverage under uninsured arrangements of group or group-type contracts, | 0011| including employer self-insured, cost-plus or other benefits methodologies not involving | 0012| insurance or not subject to New Mexico premium taxes; coverage under group-type contracts that | 0013| are not available to the general public and can be obtained only because of connection with a | 0014| particular organization or group; and coverage by medicare or other governmental benefits. | 0015| "Health plan" includes coverage through health insurance; | 0016| G. "insured" means an individual resident of this state who is eligible to receive | 0017| benefits from any insurer or other health plan; | 0018| H. "insurer" means an insurance company authorized to transact health insurance | 0019| business in this state, a nonprofit health care plan, a health maintenance organization and self | 0020| insurers not subject to federal preemption. "Insurer" does not include an insurance company that | 0021| is licensed under the Prepaid Dental Plan Law or a company that is solely engaged in the sale of | 0022| dental insurance and is licensed not under that act, but under another provision of the Insurance | 0023| Code; | 0024| I. "medicare" means coverage under both Parts A and B of Title XVIII of the | 0025| Social Security Act, as amended; | 0001| J. "medicare supplement" means coverage that offers health insurance benefits, | 0002| pursuant to Chapter 59A, Article 24 NMSA 1978, for that portion of health care services not | 0003| covered by Parts A and B of Title XVIII of the Social Security Act, as amended; | 0004| K. "pool" means the New Mexico comprehensive health insurance pool; | 0005| L. "superintendent" means the superintendent of insurance; and | 0006| M. "therapist" means a licensed physical, occupational, speech or respiratory | 0007| therapist." | 0008| Section 2. Section 59A-54-12 NMSA 1978 (being Laws 1987, Chapter 154, Section 12, | 0009| as amended) is amended to read: | 0010| "59A-54-12. ELIGIBILITY--POLICY PROVISIONS.-- | 0011| A. Except as provided in Subsection B of this section, a person is eligible for a | 0012| pool policy only if on the effective date of coverage or renewal of coverage the person is a New | 0013| Mexico resident, and: | 0014| (1) is not eligible as an insured or covered dependent for any health plan, | 0015| except as provided in Subsection G of this section, that provides coverage for comprehensive | 0016| major medical or comprehensive physician and hospital services; | 0017| (2) is only eligible for a health plan that is offered at a rate higher than | 0018| that available from the pool; | 0019| (3) has been rejected for coverage for comprehensive major medical or | 0020| comprehensive physician and hospital services; | 0021| (4) is only eligible for a health plan with a rider, waiver or restrictive | 0022| provision for that particular individual based on a specific condition; or | 0023| (5) has as of the date the individual seeks coverage from the pool an | 0024| aggregate of eighteen or more months of creditable coverage, the most recent of which was under | 0025| a group health plan, governmental plan or church plan as defined in Subsections Q, O and D, | 0001| respectively, of Section 2 of the Health Insurance Portability Act, except for the purposes of | 0002| aggregating creditable coverage a period of creditable coverage shall not be counted with respect | 0003| to enrollment of an individual for coverage under the pool, if, after that period and before the | 0004| enrollment date there was a sixty-three-day or longer period during all of which the individual | 0005| was not covered under any creditable coverage. | 0006| B. A person's eligibility for a policy issued under the Health Insurance Alliance | 0007| Act shall not preclude a person from remaining on a pool policy; provided, a self-employed | 0008| person who qualifies for an approved health plan under the Health Insurance Alliance Act by | 0009| using a dependent as the second employee may choose a pool policy in lieu of the health plan | 0010| under that act. | 0011| C. Coverage under a pool policy is in excess of and shall not duplicate coverage | 0012| under any other form of health insurance. | 0013| D. A pool policy shall provide that coverage of a dependent unmarried person | 0014| terminates when the person becomes nineteen years of age or, if the person is enrolled full time | 0015| in an accredited educational institution, when he becomes twenty-five years of age. The policy | 0016| shall also provide in substance that attainment of the limiting age does not operate to terminate | 0017| coverage when the person is and continues to be: | 0018| (1) incapable of self-sustaining employment by reason of developmental | 0019| disability or physical handicap; and | 0020| (2) primarily dependent for support and maintenance upon the person in | 0021| whose name the contract is issued. | 0022| Proof of incapacity and dependency shall be furnished to the insurer within one hundred | 0023| twenty days of attainment of the limiting age and subsequently as required by the insurer but not | 0024| more frequently than annually after the two-year period following attainment of the limiting age. | 0025| E. A pool policy that provides coverage for a family member of the person in | 0001| whose name the contract is issued shall, as to the coverage of the family member or the | 0002| individual in whose name the contract was issued, provide that the health insurance benefits | 0003| applicable for children are payable with respect to a newly born child of the family member or | 0004| the person in whose name the contract is issued from the moment of coverage of injury or illness, | 0005| including the necessary care and treatment of medically diagnosed congenital defects and birth | 0006| abnormalities. If payment of a specific premium is required to provide coverage for the child, the | 0007| contract may require that notification of the birth of a child and payment of the required premium | 0008| shall be furnished to the carrier within thirty-one days after the date of birth in order to have the | 0009| coverage continued beyond the thirty-one day period. | 0010| F. Except for a person eligible as provided in paragraph (5) of Subsection A of | 0011| this section, a pool policy may contain provisions under which coverage is excluded during a six- | 0012| month period following the effective date of coverage as to a given individual for preexisting | 0013| conditions, as long as either of the following exists: | 0014| (1) the condition has manifested itself within a period of six months | 0015| before the effective date of coverage in such a manner as would cause an ordinarily prudent | 0016| person to seek diagnoses or treatment; or | 0017| (2) medical advice or treatment was recommended or received within a | 0018| period of six months before the effective date of coverage. | 0019| G. The preexisting condition exclusions described in Subsection E of this section | 0020| shall be waived to the extent to which similar exclusions have been satisfied under any prior | 0021| health insurance coverage which was involuntarily terminated, if the application for pool | 0022| coverage is made not later than thirty-one days following the involuntary termination. In that | 0023| case, coverage in the pool shall be effective from the date on which the prior coverage was | 0024| terminated. This subsection does not prohibit preexisting conditions coverage in a pool policy | 0025| that is more favorable to the insured than that specified in this subsection. | 0001| H. A person under the age of sixty-five who meets the criteria established in | 0002| Subsection A of this section and who is eligible for and receiving medicare because of a | 0003| disability is eligible for a medicare supplement pool policy. | 0004| I. Except as provided in Subsection G of this section, an individual is not eligible | 0005| for coverage by the pool if: | 0006| (1) he is, at the time of application, eligible for medicare or medicaid | 0007| which would provide coverage for amounts in excess of limited policies such as dread disease, | 0008| cancer policies or hospital indemnity policies; | 0009| (2) he has terminated coverage by the pool within the past twelve months; | 0010| (3) he is an inmate of a public institution or is eligible for public programs | 0011| for which medical care is provided; | 0012| (4) he is eligible for coverage under a group health plan; | 0013| (5) he has other health insurance coverage; | 0014| (6) the most recent coverages within the coverage period described in | 0015| Paragraph (5) of Subsection A of this section was terminated as a result of nonpayment of | 0016| premium or fraud; or | 0017| (7) he has been offered the option of continuation coverage under a | 0018| federal COBRA continuation provision as defined in Subsection F of Section 2 of the Health | 0019| Insurance Portability Act or under a similar state program, and he has elected the coverage and | 0020| did not exhaust the continuation coverage under the provision or program. | 0021| J. Any person whose health insurance coverage from a qualified state health | 0022| policy with similar coverage is terminated because of nonresidency in another state may apply for | 0023| coverage under the pool. If the coverage is applied for within thirty-one days after that | 0024| termination and if premiums are paid for the entire coverage period, the effective date of the | 0025| coverage shall be the date of termination of the previous coverage." | 0001| Section 3. Section 59A-54-13 NMSA 1978 (being Laws 1987, Chapter 154, Section 13, | 0002| as amended) is amended to read: | 0003| "59A-54-13. BENEFITS.-- | 0004| A. The health insurance policy issued by the pool shall pay for medically | 0005| necessary eligible health care services rendered or furnished for the diagnoses or treatment of | 0006| illness or injury that exceed the deductible and coinsurance amounts applicable under Section | 0007| 59A-54-14 NMSA 1978 and are not otherwise limited or excluded. Eligible expenses are the | 0008| charges for the health care services and items for which benefits are extended under the pool | 0009| policy. The coverage to be issued by the pool and its schedule of benefits, exclusions and other | 0010| limitations shall be established by the board and shall, at a minimum, reflect the levels of health | 0011| insurance coverage generally available in New Mexico for small group policies. The | 0012| superintendent shall approve the benefit package developed by the board to ensure its compliance | 0013| with the Comprehensive Health Insurance Pool Act. The benefit package shall include therapy | 0014| services and hearing aids. | 0015| B. The pool shall make available medicare supplement coverage for individuals | 0016| under the age of sixty-five who meet the criteria established in Subsection A of Section | 0017| 59A-54-12 NMSA 1978 and who are eligible for and receive medicare because of a disability. | 0018| C. The Comprehensive Health Insurance Pool Act shall not be construed to | 0019| prohibit the pool from issuing additional types of health insurance policies with different types of | 0020| benefits which in the opinion of the board may be of benefit to the citizens of New Mexico. | 0021| D. The board may design and employ cost containment measures and | 0022| requirements, including preadmission certification and concurrent inpatient review, for the | 0023| purpose of making the pool more cost effective." | 0024| Section 4. Section 59A-54-14 NMSA 1978 (being Laws 1987, Chapter 154, Section 14, | 0025| as amended) is amended to read: | 0001| "59A-54-14. DEDUCTIBLES--COINSURANCE--MAXIMUM OUT-OF-POCKET | 0002| PAYMENTS.-- | 0003| A. Except for medicare supplement coverage authorized by Subsection B of | 0004| Section 59A-54-13 NMSA 1978, and subject to the limitation provided in Subsection C of this | 0005| section, a pool policy offered in accordance with the Comprehensive Health Insurance Pool Act | 0006| shall impose a deductible on a per-person calendar-year basis. Deductible plans of five hundred | 0007| dollars ($500) and one thousand dollars ($1,000) shall initially be offered. The board may | 0008| authorize deductibles in other amounts. The deductible shall be applied to the first five hundred | 0009| dollars ($500) or one thousand dollars ($1,000) of eligible expenses incurred by the covered | 0010| person. | 0011| B. Except for medicare supplement coverage authorized by Subsection B of | 0012| Section 59A-54-13 NMSA 1978, and subject to the limitations provided in Subsection C of this | 0013| section, a mandatory coinsurance requirement shall be imposed at the rate of twenty percent of | 0014| eligible expenses in excess of the mandatory deductible. | 0015| C. The maximum aggregate out-of-pocket payments for eligible expenses | 0016| by the insured shall be determined by the board." |