0001|                            HOUSE BILL 493
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0002|     43RD LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION, 1998
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0003|                            INTRODUCED BY
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0004|                          TERRY T. MARQUARDT
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0005|     
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0006|                                   
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0007|     
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0008|     
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0009|     
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0010|                                AN ACT
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0011|     RELATING TO INSURANCE; AUTHORIZING THE DEPARTMENT OF INSURANCE
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0012|     TO DEVELOP AND ADMINISTER A CHILDREN'S HEALTH INSURANCE
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0013|     PROGRAM; PROVIDING DEFINITIONS; PROVIDING FOR MINIMUM COVERAGE
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0014|     AND LIMITATIONS.
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0015|     
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0016|     
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0017|     BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0018|          Section 1.  SHORT TITLE.--This act may be cited as the
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0019|     "New Mexico Children's Health Insurance Program Act".
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0020|          Section 2.  PURPOSE.--The purpose of the New Mexico
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0021|     Children's Health Insurance Program Act is to create a
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0022|     children's health insurance program eligible for payment under
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0023|     Section 2105 of the federal Social Security Act.  The program
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0024|     will expand the health insurance options of targeted low-
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0025|     income children through the services of private health
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0001|     insurers meeting the requirements of Sections 5 and 7 of the
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0002|     New Mexico Children's Health Insurance Program Act that
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0003|     contract with the department to provide targeted low-income
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0004|     children with health insurance coverage.
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0005|          Section 3.  DEFINITIONS.--As used in the New Mexico
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0006|     Children's Health Insurance Program Act:
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0007|               A.  "child" means a natural person less than
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0008|     nineteen years of age who is a resident of this state;
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0009|               B.  "creditable health coverage" has the meaning
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0010|     given the term "creditable coverage" under Section 2701(c) of
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0011|     the federal Public Health Service Act and includes coverage
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0012|     that meets the requirements of Section 2103 of the federal
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0013|     Social Security Act provided to a targeted low-income child
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0014|     under the New Mexico Children's Health Insurance Program Act
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0015|     or under a waiver approved under Section 2105(c)(2)(B) of the
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0016|     federal Social Security Act;
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0017|               C.  "department" means the department of insurance;
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0018|               D.  "group health plan" has the meaning given such
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0019|     term under Section 2791 of the federal Public Health Service
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0020|     Act;
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0021|               E.  "health insurance coverage" has the meaning
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0022|     given such term under Section 2791(b)(1) of the federal Public
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0023|     Health Service Act;
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0024|               F.  "low-income child" means a child whose family
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0025|     income is at or below two hundred percent of poverty;
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0001|               G.  "participating insurer" means any entity
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0002|     licensed to provide health insurance in this state that has
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0003|     contracted with the department to offer health insurance
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0004|     coverage to targeted low-income children pursuant to the New
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0005|     Mexico Children's Health Insurance Program Act;
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0006|               H.  "poverty" has the meaning given such term in
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0007|     Section 673(2) of the federal Community Services Block Grant
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0008|     Act, including any revision required by such section;
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0009|               I.  "preexisting condition exclusion" has the
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0010|     meaning given such term in Section 2701(b)(1)(A) of the
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0011|     federal Public Health Service Act;
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0012|               J.  "qualified child health plan" means health
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0013|     insurance coverage provided by a participating insurer
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0014|     consistent with Section 7 of the New Mexico Children's Health
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0015|     Insurance Program Act; and
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0016|               K.  "targeted low-income child" means a child,
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0017|     except as provided by Paragraph (3) of this subsection, who:
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0018|                    (1)  has been determined eligible under the
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0019|     New Mexico Children's Health Insurance Program Act;
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0020|                    (2)  is a low-income child or is a child whose
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0021|     family income exceeds the medicaid-applicable income level of
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0022|     New Mexico by not more than fifty percentage points;
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0023|                    (3)  is not found to be eligible for medicaid
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0024|     or covered under a group health plan or under health insurance
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0025|     coverage, including a health insurance coverage program
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0001|     offered by New Mexico that receives no federal funds and that
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0002|     has been in operation since before July 1, 1997; and
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0003|                    (4)  "targeted low-income child" does not
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0004|     include:
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0005|                         (a)  a child who is an inmate of a
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0006|     public institution or a patient in an institution or a patient
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0007|     in an institution for mental diseases; or
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0008|                         (b)  a child who is a member of a family
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0009|     that is eligible for health benefits coverage under a state
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0010|     employee health benefits plan.
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0011|          Section 4.  PROGRAM ADMINISTRATION--FINANCING.--
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0012|               A.  The department shall prepare a state children's
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0013|     health insurance program for submission to and approval by the
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0014|     secretary of the federal department of health and human
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0015|     services within ninety day of the effective date of the New
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0016|     Mexico Children's Health Insurance Program Act.
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0017|               B.  The department shall administer the program,
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0018|     after approval of the secretary of the federal health and
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0019|     human services department, by entering into contracts with at
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0020|     least two insurers and at least two health maintenance
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0021|     organizations that offer a qualified child health plan.
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0022|               C.  The human services department shall be
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0023|     responsible for certifying to the department the eligibility
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0024|     of children for the state children's health insurance program.
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0025|               D.  Upon notice of enrollment of a targeted low-
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0001|     income child in a qualified child health plan, the department
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0002|     shall forward the annual negotiated cost of insuring each
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0003|     targeted low-income child to the appropriate participating
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0004|     insurer.
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0005|               E.  In no event shall more than ten percent of the
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0006|     total program appropriation be used for:
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0007|                    (1)  other children's health programs for
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0008|     targeted low-income children;
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0009|                    (2)  initiatives for improving the health of
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0010|     children, including targeted low-income and other low-income
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0011|     children;
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0012|                    (3)  outreach activities that inform families
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0013|     of children who are likely to be eligible for this program or
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0014|     other public or private health coverage programs, or for
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0015|     coordination of the administration of this program with other
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0016|     public and private health insurance programs; and
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0017|                    (4)  other reasonable costs incurred by the
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0018|     department administering the program.
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0019|          Section 5.  INSURER PROVISIONS.--
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0020|               A.  A participating insurer shall offer a qualified
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0021|     child health plan to eligible children without regard to
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0022|     health status and without the imposition of a preexisting
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0023|     condition exclusion, except that a preexisting condition
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0024|     exclusion may be applied if the qualified child health plan is
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0025|     provided through a group health plan or group health insurance
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0001|     coverage, consistent with the limitations on the imposition of
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0002|     preexisting condition exclusions in connection with such
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0003|     coverage.
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0004|               B.  Premium and cost-sharing amounts are limited as
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0005|     follows:
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0006|                    (1)  no deductibles, co-insurance or other
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0007|     cost sharing is permitted with respect to benefits for well-
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0008|     baby and well-child care, including age-appropriate
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0009|     immunizations;
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0010|                    (2)  for children whose family income is at or
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0011|     below one hundred fifty percent of poverty:
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0012|                         (a)  premiums, enrollment fees or
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0013|     similar charges may not exceed the maximum monthly charge
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0014|     permitted consistent with standards established to carry out
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0015|     Section 1916(b)(1) of the federal Social Security Act; and 
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0016|                         (b)  deductibles and other cost sharing
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0017|     shall not exceed an amount that is nominal consistent with
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0018|     standards provided under Section 1916(a)(3) of the federal
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0019|     Social Security Act; and
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0020|                    (3)  for children whose family income is more
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0021|     than one hundred fifty percent of poverty, premiums,
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0022|     deductibles and other cost sharing may be imposed on a sliding
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0023|     scale related to income; provided that the total annual
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0024|     aggregate cost sharing with respect to all targeted low-income
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0025|     children in a family under the New Mexico Children's Health
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0001|     Insurance Program Act shall not exceed five percent of such
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0002|     family's income for the year involved.
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0003|               C.  Existing health insurance sales and marketing
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0004|     methods, including the use of agents and payment of
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0005|     commissions, shall be utilized to inform families of the
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0006|     availability of the New Mexico children's health insurance
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0007|     program and assist them in obtaining coverage for children
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0008|     under the program.
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0009|          Section 6.  ELIGIBILITY PROVISIONS.--
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0010|               A.  Targeted low-income children shall be eligible
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0011|     for coverage with a participating insurer regardless of health
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0012|     status.
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0013|               B.  Eligible children shall be allowed to change
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0014|     enrollment between participating insurers upon the annual
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0015|     coverage renewal date, provided that at least six months'
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0016|     notice of an election to change enrollment is provided to the
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0017|     participating insurer with which the child is currently
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0018|     enrolled.  The notice provision shall be reduced to sixty days
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0019|     if the child has changed residence to an area outside the
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0020|     geographic service area of the participating insurer with
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0021|     which the child is currently enrolled.
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0022|          Section 7.  SCOPE OF BENEFITS.--At a minimum, a qualified
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0023|     child health plan shall contain benefits consistent with the
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0024|     provisions of Subsections A through C of this section:
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0025|               A.  health insurance coverage equivalent to one of
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0001|     the following:
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0002|                    (1)  the standard blue cross-blue shield
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0003|     preferred provider option under the federal employees health
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0004|     benefit plan;
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0005|                    (2)  a health benefits coverage plan that is
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0006|     offered and generally available to state employees; or
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0007|                    (3)  health insurance coverage offered by a
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0008|     health maintenance organization that has the largest insured
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0009|     commercial, non-medicaid enrollment of covered lives in the
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0010|     state;
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0011|               B.  
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0012|                    (1)  health insurance coverage that has an
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0013|     aggregate actuarial value at least equivalent to that
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0014|     established in Subsection A of this section and that includes
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0015|     coverage for the following basic services:
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0016|                         (a)  inpatient and outpatient hospital
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0017|     services;
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0018|                         (b)  physicians' surgical and medical
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0019|     services;
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0020|                         (c)  laboratory and x-ray services; and
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0021|                         (d)  well-baby and well-child care,
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0022|     including age-appropriate immunizations; or 
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0023|                    (2)  health insurance coverage based on
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0024|     actuarial equivalence for basic services, as described in
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0025|     Paragraph (1) of this subsection, may provide the following
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0001|     additional services if the coverage for such services has an
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0002|     actuarial value of at least seventy-five percent of the
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0003|     actuarial value of the coverage provided in that category of
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0004|     services in such package:
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0005|                         (a)  coverage of prescription drugs;
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0006|                         (b)  mental health services;
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0007|                         (c)  vision services; and
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0008|                         (d)  hearing services; or
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0009|               C.  upon application by the department, any other
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0010|     health insurance coverage that has been approved by the
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0011|     secretary of the federal health and human services department.
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0012|                              
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