0001| SENATE BILL 571 | 0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0003| INTRODUCED BY | 0004| CARROLL H. LEAVELL | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| AN ACT | 0011| RELATING TO INSURANCE; PERMITTING PERSONS WITH A DISABILITY TO | 0012| ACQUIRE MEDICARE SUPPLEMENT HEALTH INSURANCE UNDER CERTAIN | 0013| CIRCUMSTANCES. | 0014| | 0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0016| Section 1. Section 59A-54-3 NMSA 1978 (being Laws 1987, | 0017| Chapter 154, Section 3, as amended) is amended to read: | 0018| "59A-54-3. DEFINITIONS.--As used in the Comprehensive | 0019| Health Insurance Pool Act: | 0020| A. "board" means the board of directors of the | 0021| pool; | 0022| B. "health care facility" means any entity | 0023| providing health care services that is licensed by the | 0024| department of health; | 0025| C. "health care services" means any services or | 0001| products included in the furnishing to any individual of | 0002| medical care or hospitalization or incidental to the furnishing | 0003| of such care or hospitalization, as well as the furnishing to | 0004| any person of any other services or products for the purpose of | 0005| preventing, alleviating, curing or healing human illness or | 0006| injury; | 0007| D. "health insurance" means any hospital and | 0008| medical expense-incurred policy, nonprofit health care service | 0009| plan contract, health maintenance organization subscriber | 0010| contract, short-term, accident, fixed indemnity, specified | 0011| disease policy or disability income contracts and limited | 0012| benefit or credit insurance, or as defined by Section 59A-7-3 | 0013| NMSA 1978. The term does not include insurance arising out of | 0014| the Workers' Compensation Act or similar law, automobile | 0015| medical payment insurance or insurance under which benefits are | 0016| payable with or without regard to fault and which is required | 0017| by law to be contained in any liability insurance policy; | 0018| E. "health maintenance organization" means any | 0019| person who provides, at a minimum, either directly or through | 0020| contractual or other arrangements with others, basic health | 0021| care services to enrollees on a fixed prepayment basis and who | 0022| is responsible for the availability, accessibility and quality | 0023| of the health care services provided or arranged, or as defined | 0024| by Subsection F of Section 59A-46-2 NMSA 1978; | 0025| F. "health plan" means any arrangement by which | 0001| persons, including dependents or spouses, covered or making | 0002| application to be covered under the pool have access to | 0003| hospital and medical benefits or reimbursement, including group | 0004| or individual insurance or subscriber contract; coverage | 0005| through health maintenance organizations, preferred provider | 0006| organizations or other alternate delivery systems; coverage | 0007| under prepayment, group practice or individual practice plans; | 0008| coverage under uninsured arrangements of group or group-type | 0009| contracts, including employer self-insured, cost-plus or other | 0010| benefits methodologies not involving insurance or not subject | 0011| to New Mexico premium taxes; coverage under group-type | 0012| contracts which are not available to the general public and can | 0013| be obtained only because of connection with a particular | 0014| organization or group; and coverage by medicare or other | 0015| governmental benefits. The term includes coverage through | 0016| health insurance; | 0017| G. "insured" means an individual resident of this | 0018| state who is eligible to receive benefits from any insurer or | 0019| other health plan; | 0020| H. "insurer" means an insurance company authorized | 0021| to transact health insurance business in this state, a | 0022| nonprofit health care plan, a health maintenance organization | 0023| and self insurers not subject to federal preemption. "Insurer" | 0024| does not include an insurance company that is licensed under | 0025| the Prepaid Dental Plan Law or a company that is solely engaged | 0001| in the sale of dental insurance and is licensed not under that | 0002| act, but under another provision of the Insurance Code; | 0003| I. "medicare" means coverage under both [Part] | 0004| Parts A and B of Title XVIII of the Social Security Act, [42 | 0005| USC 1395 et seq.] as amended; | 0006| J. "medicare supplement" means coverage that | 0007| offers health insurance benefits, pursuant to Chapter 59A, | 0008| Article 24 NMSA 1978, for that portion of health care services | 0009| not covered by Parts A and B of Title XVIII of the Social | 0010| Security Act, as amended; | 0011| [J.] K. "pool" means the New Mexico | 0012| comprehensive health insurance pool; | 0013| [K.] L. "superintendent" means the | 0014| superintendent of insurance; and | 0015| [L.] M. "therapist" means a licensed physical, | 0016| occupational, speech or respiratory therapist." | 0017| Section 2. Section 59A-54-12 NMSA 1978 (being Laws 1987, | 0018| Chapter 154, Section 12, as amended) is amended to read: | 0019| "59A-54-12. ELIGIBILITY--POLICY PROVISIONS.-- | 0020| A. A person is eligible for a pool policy only if | 0021| on the effective date of coverage or renewal of coverage the | 0022| person is a New Mexico resident, and: | 0023| (1) is not eligible as an insured or covered | 0024| dependent for any health plan, except as provided in | 0025| Subsection G of this section, that provides coverage for | 0001| comprehensive major medical or comprehensive physician and | 0002| hospital services; | 0003| (2) is only eligible for a health plan that is | 0004| offered at a rate higher than that available from the pool; | 0005| (3) has been rejected for coverage for | 0006| comprehensive major medical or comprehensive physician and | 0007| hospital services; or | 0008| (4) is only eligible for a health plan with a | 0009| rider, waiver or restrictive provision for that particular | 0010| individual based on a specific condition. | 0011| B. Coverage under a pool policy is in excess of and | 0012| shall not duplicate coverage under any other form of health | 0013| insurance. | 0014| C. A pool policy shall provide that coverage of a | 0015| dependent unmarried person terminates when the person becomes | 0016| nineteen years of age or, if the person is enrolled full time | 0017| in an accredited educational institution, when he becomes | 0018| twenty-five years of age. The policy shall also provide in | 0019| substance that attainment of the limiting age does not operate | 0020| to terminate coverage when the person is and continues to be: | 0021| (1) incapable of self-sustaining employment by | 0022| reason of mental retardation or physical handicap; and | 0023| (2) primarily dependent for support and | 0024| maintenance upon the person in whose name the contract is | 0025| issued. | 0001| Proof of incapacity and dependency shall be furnished to | 0002| the insurer within one hundred twenty days of attainment of the | 0003| limiting age and subsequently as required by the insurer but | 0004| not more frequently than annually after the two-year period | 0005| following attainment of the limiting age. | 0006| D. A pool policy that provides coverage for a | 0007| family member of the person in whose name the contract is | 0008| issued shall, as to the coverage of the family member or the | 0009| individual in whose name the contract was issued, provide that | 0010| the health insurance benefits applicable for children are | 0011| payable with respect to a newly born child of the family member | 0012| or the person in whose name the contract is issued from the | 0013| moment of coverage of injury or illness, including the | 0014| necessary care and treatment of medically diagnosed congenital | 0015| defects and birth abnormalities. If payment of a specific | 0016| premium is required to provide coverage for the child, the | 0017| contract may require that notification of the birth of a child | 0018| and payment of the required premium shall be furnished to the | 0019| carrier within thirty-one days after the date of birth in order | 0020| to have the coverage continued beyond the thirty-one day | 0021| period. | 0022| E. A pool policy may contain provisions under which | 0023| coverage is excluded during a six-month period following the | 0024| effective date of coverage as to a given individual for | 0025| preexisting conditions, as long as either of the following | 0001| exists: | 0002| (1) the condition has manifested itself within | 0003| a period of six months before the effective date of coverage in | 0004| such a manner as would cause an ordinarily prudent person to | 0005| seek diagnoses or treatment; or | 0006| (2) medical advice or treatment was | 0007| recommended or received within a period of six months before | 0008| the effective date of coverage. | 0009| F. The preexisting condition exclusions described | 0010| in Subsection E of this section shall be waived to the extent | 0011| to which similar exclusions have been satisfied under any prior | 0012| health insurance coverage which was involuntarily terminated, | 0013| if the application for pool coverage is made not later than | 0014| thirty-one days following the involuntary termination. In that | 0015| case, coverage in the pool shall be effective from the date on | 0016| which the prior coverage was terminated. This subsection does | 0017| not prohibit preexisting conditions coverage in a pool policy | 0018| that is more favorable to the insured than that specified in | 0019| this subsection. | 0020| G. A person under the age of sixty-five who meets | 0021| the criteria established in Subsection A of this section and | 0022| who is eligible for and receiving medicare because of a | 0023| disability is eligible for a medicare supplement pool policy. | 0024| [G.] H. Except as provided in Subsection G of | 0025| this section, an individual is not eligible for coverage by | 0001| the pool if: | 0002| (1) he is, at the time of application, | 0003| eligible for medicare or medicaid which would provide coverage | 0004| for amounts in excess of limited policies such as dread | 0005| disease, cancer policies or hospital indemnity policies; | 0006| (2) he has terminated coverage by the pool | 0007| within the past twelve months; or | 0008| (3) he is an inmate of a public institution or | 0009| is eligible for public programs for which medical care is | 0010| provided. | 0011| [H.] I. Any person whose health insurance | 0012| coverage from a qualified state health policy with similar | 0013| coverage is terminated because of nonresidency in another state | 0014| may apply for coverage under the pool. If the coverage is | 0015| applied for within thirty-one days after that termination and | 0016| if premiums are paid for the entire coverage period, the | 0017| effective date of the coverage shall be the date of termination | 0018| of the previous coverage." | 0019| Section 3. Section 59A-54-13 NMSA 1978 (being Laws 1987, | 0020| Chapter 154, Section 13, as amended) is amended to read: | 0021| "59A-54-13. BENEFITS.-- | 0022| A. The health insurance policy issued by the pool | 0023| shall pay for medically necessary eligible health care services | 0024| rendered or furnished for the diagnoses or treatment of illness | 0025| or injury that [exceeds] exceed the deductible and | 0001| coinsurance amounts applicable under Section 59A-54-14 NMSA | 0002| 1978 and are not otherwise limited or excluded. Eligible | 0003| expenses are the charges for the health care services and items | 0004| for which benefits are extended under the pool policy. The | 0005| coverage to be issued by the pool and its schedule of | 0006| benefits, exclusions and other limitations shall be established | 0007| by the board and shall, at a minimum, reflect the levels of | 0008| health insurance coverage generally available in New Mexico for | 0009| small group policies. The superintendent shall approve the | 0010| benefit package developed by the board to ensure its compliance | 0011| with the Comprehensive Health Insurance Pool Act. The benefit | 0012| package shall include therapy services and hearing aids. | 0013| B. The pool shall make available medicare | 0014| supplement coverage for individuals under the age of sixty-five | 0015| who meet the criteria established in Subsection A of Section | 0016| 59A-54-12 NMSA 1978 and who are eligible for and receive | 0017| medicare because of a disability. | 0018| [B.] C. The Comprehensive Health Insurance Pool | 0019| Act shall not be construed to prohibit the pool from issuing | 0020| additional types of health insurance policies with different | 0021| types of benefits which in the opinion of the board may be of | 0022| benefit to the citizens of New Mexico. | 0023| [C.] D. The board may design and employ cost | 0024| containment measures and requirements, including preadmission | 0025| certification and concurrent inpatient review, for the purpose | 0001| of making the pool more cost effective." | 0002| Section 4. Section 59A-54-14 NMSA 1978 (being Laws 1987, | 0003| Chapter 154, Section 14, as amended) is amended to read: | 0004| "59A-54-14. DEDUCTIBLES--COINSURANCE--MAXIMUM OUT-OF- | 0005| POCKET PAYMENTS.-- | 0006| A. Except for medicare supplement coverage | 0007| authorized by Subsection B of Section 59A-54-13 NMSA 1978, and | 0008| subject to the limitation provided in Subsection C of this | 0009| section, a pool policy offered in accordance with the | 0010| Comprehensive Health Insurance Pool Act shall impose a | 0011| deductible on a per-person calendar-year basis. Deductible | 0012| plans of five hundred dollars ($500) and one thousand dollars | 0013| ($1,000) shall initially be offered. The board may authorize | 0014| deductibles in other amounts. The deductible shall be applied | 0015| to the first five hundred dollars ($500) or one thousand | 0016| dollars ($1,000) of eligible expenses incurred by the covered | 0017| person. | 0018| B. Except for medicare supplement coverage | 0019| authorized by Subsection B of Section 59A-54-13 NMSA 1978, and | 0020| subject to the limitations provided in Subsection C of this | 0021| section, a mandatory coinsurance requirement shall be imposed | 0022| at the rate of twenty percent of eligible expenses in excess of | 0023| the mandatory deductible. | 0024| C. The maximum aggregate out-of-pocket payments for | 0025| eligible expenses by the insured shall be determined by the | 0001| board." | 0002|  | 0003| | 0004| FORTY-THIRD LEGISLATURE | 0005| FIRST SESSION, 1997 | 0006| | 0007| | 0008| | 0009| February 28, 1997 | 0010| | 0011| Mr. President: | 0012| | 0013| Your PUBLIC AFFAIRS COMMITTEE, to whom has been | 0014| referred | 0015| | 0016| SENATE BILL 571 | 0017| | 0018| has had it under consideration and reports same with | 0019| recommendation that it DO PASS, and thence referred to the | 0020| CORPORATIONS & TRANSPORTATION COMMITTEE. | 0021| | 0022| Respectfully submitted, | 0023| | 0024| | 0025| | 0001| | 0002| __________________________________ | 0003| Shannon Robinson, Chairman | 0004| | 0005| | 0006| | 0007| Adopted_______________________ Not | 0008| Adopted_______________________ | 0009| (Chief Clerk) (Chief Clerk) | 0010| | 0011| | 0012| Date ________________________ | 0013| | 0014| | 0015| The roll call vote was 5 For 0 Against | 0016| Yes: 5 | 0017| No: 0 | 0018| Excused: Boitano, Garcia, Ingle, Smith | 0019| Absent: None | 0020| | 0021| | 0022| S0571PA1 | 0023| | 0024| | 0025| | 0001| FORTY-THIRD LEGISLATURE | 0002| FIRST SESSION, 1997 | 0003| | 0004| | 0005| March 4, 1997 | 0006| | 0007| Mr. President: | 0008| | 0009| Your CORPORATIONS & TRANSPORTATION COMMITTEE, to | 0010| whom has been referred | 0011| | 0012| SENATE BILL 571 | 0013| | 0014| has had it under consideration and reports same with | 0015| recommendation that it DO PASS. | 0016| | 0017| Respectfully submitted, | 0018| | 0019| | 0020| | 0021| | 0022| __________________________________ | 0023| Roman M. Maes, III, Chairman | 0024| | 0025| | 0001| | 0002| Adopted_______________________ Not | 0003| Adopted_______________________ | 0004| (Chief Clerk) (Chief Clerk) | 0005| | 0006| | 0007| | 0008| Date ________________________ | 0009| | 0010| | 0011| The roll call vote was 8 For 0 Against | 0012| Yes: 8 | 0013| No: 0 | 0014| Excused: Fidel, Robinson | 0015| Absent: None | 0016| | 0017| | 0018| S0571CT1 | 0019| State of New Mexico | 0020| House of Representatives | 0021| | 0022| FORTY-THIRD LEGISLATURE | 0023| FIRST SESSION, 1997 | 0024| | 0025| | 0001| March 22, 1997 | 0002| | 0003| | 0004| Mr. Speaker: | 0005| | 0006| Your BUSINESS AND INDUSTRY COMMITTEE, to whom has | 0007| been referred | 0008| | 0009| SENATE BILL 571 | 0010| | 0011| has had it under consideration and reports same with | 0012| recommendation that it DO PASS. | 0013| | 0014| Respectfully submitted, | 0015| | 0016| | 0017| | 0018| | 0019| Fred Luna, Chairman | 0020| | 0021| | 0022| Adopted Not Adopted | 0023| | 0024| (Chief Clerk) (Chief Clerk) | 0025| | 0001| Date | 0002| | 0003| The roll call vote was 7 For 1 Against | 0004| Yes: 7 | 0005| No: Lutz | 0006| Excused: Alwin, Chavez, Getty, Gubbels, Varela | 0007| Absent: None | 0008| | 0009| | 0010| G:\BILLTEXT\BILLW_97\S0571 |