HOUSE BILL 298
46th legislature - STATE OF NEW MEXICO - second session, 2004
INTRODUCED BY
Antonio Lujan
FOR THE LEGISLATIVE HEALTH AND HUMAN SERVICES COMMITTEE
AN ACT
RELATING TO HEALTH INSURANCE; ADDING AN INSURANCE PROGRAM TO THOSE CURRENTLY OFFERED BY THE NEW MEXICO HEALTH INSURANCE ALLIANCE; PERMITTING ADDITIONAL SERVICES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. A new section of the Health Insurance Alliance Act is enacted to read:
"[NEW MATERIAL] PLAN INCLUDED.--The board shall adopt rules to include in the approved health plans offered by the alliance that health insurance program created by the human services department pursuant to the federal health insurance flexibility and accountability demonstration initiative approved for New Mexico August 23, 2002."
Section 2. Section 59A-56-8 NMSA 1978 (being Laws 1994, Chapter 75, Section 8, as amended) is amended to read:
"59A-56-8. APPROVED HEALTH PLAN.--
A. An approved health plan shall conform to the alliance's approved health plan design criteria. The board may allow more than one plan design for approved health plans. A member may provide one approved health plan for each plan design approved by the board.
B. The board shall designate plan designs for approved health plans. The board may designate plan designs for an approved health plan that provides catastrophic coverage or other benefit plan designs. The board shall designate plan designs that include services provided by a preferred provider arrangement or by a point of service plan.
C. Each approved health plan shall offer a premium that is no greater than fifteen percent over and no less than fifteen percent under the average of the standard rate index for plans with the same characteristics.
D. Each approved health plan offered to an eligible individual shall offer a premium that is no more than twenty-five percent over and no less than twenty-five percent under the average of the standard risk rate index determined pursuant to Section 59A-56-23 NMSA 1978.
E. Any member that provides or offers to renew a group health insurance contract providing health insurance benefits to employees of the state, a county, a municipality or a school district for which public funds are contributed shall offer at least one approved health plan to small employers and eligible individuals; provided, however, if a member does not offer anywhere in the United States a plan that meets substantially the design criteria of an approved health plan, the member shall not be required to offer an approved health plan.
F. If a plan design approved by the board is not offered by any member already offering an approved health plan, but a member offers a substantially similar plan design outside the alliance, the board may require the member to offer that plan design as an approved health plan through the alliance.
G. A member required to offer, and offering, an approved health plan pursuant to the requirement of Subsection E of this section shall continue to offer that plan for five consecutive years after the date the member was last required to offer the plan. A member offering an approved health plan but not required to offer it pursuant to the cited subsection may withdraw the plan but shall continue to offer it for five consecutive years after the date notice of future withdrawal is given to the board unless:
(1) the member substitutes another approved health plan for the plan withdrawn; or
(2) the board allows the plan to be withdrawn because it imposes a serious hardship upon the member.
H. No member shall be required to offer an approved health plan if the member notifies the superintendent in writing that it will no longer offer health insurance, life insurance or annuities in the state, except for renewal of existing contracts, provided that:
(1) the member does not offer or provide health insurance, life insurance or annuities for a period of five years from the date of notification to the superintendent to any person in the state who is not covered by the member through a health insurance policy in effect on the date of the notification; and
(2) with respect to health or life insurance policies or annuities in effect on the date of notification to the superintendent, the member continues to comply with all applicable laws and regulations governing the provision of insurance in this state, including the payment of applicable taxes, fees and assessments."
Section 3. Section 59A-56-14 NMSA 1978 (being Laws 1994, Chapter 75, Section 14, as amended) is amended to read:
"59A-56-14. ELIGIBILITY--GUARANTEED ISSUE--PLAN PROVISIONS.--
A. A small employer is eligible for an approved health plan if on the effective date of coverage or renewal:
(1) at least fifty percent of its employees not otherwise insured elect to be covered under the approved health plan;
(2) the small employer has not terminated coverage with an approved health plan within three years of the date of application for coverage except to change to another approved health plan; and
(3) the small employer does not offer other general group health insurance coverage to its employees. For the purposes of this paragraph, general group health insurance coverage excludes:
(a) coverage providing only a specific limited form of health insurance such as accident or disability income insurance coverage or a specific health care service such as dental care; and
(b) a plan offered by the alliance created by the human services department pursuant to the federal health insurance flexibility and accountability demonstration initiative approved for New Mexico August 23, 2002.
B. An individual is eligible for an approved health plan if on the effective date of coverage or renewal he meets the definition of an eligible individual under Section 59A-56-3 NMSA 1978.
C. An approved health plan shall provide in substance that attainment of the limiting age by an unmarried dependent individual does not operate to terminate coverage when the individual continues to be incapable of self-sustaining employment by reason of developmental disability or physical handicap and the individual is primarily dependent for support and maintenance upon the employee. Proof of incapacity and dependency shall be furnished to the alliance and the member that offered the approved health plan within one hundred twenty days of attainment of the limiting age. The board may require subsequent proof annually after a two-year period following attainment of the limiting age.
D. An approved health plan shall provide that the health insurance benefits applicable for eligible dependents are payable with respect to a newly born child of the family member or the individual in whose name the contract is issued from the moment of birth, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. If payment of a specific premium is required to provide coverage for the child, the contract may require that notification of the birth of a child and payment of the required premium shall be furnished to the member within thirty-one days after the date of birth in order to have the coverage from birth. An approved health plan shall provide that the health insurance benefits applicable for eligible dependents are payable for an adopted child in accordance with the provisions of Section 59A-22-34.1 NMSA 1978.
E. Except as provided in Subsections G, H and I of this section, an approved health plan offered to a small employer may contain a preexisting condition exclusion only if:
(1) the exclusion relates to a condition, physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date;
(2) the exclusion extends for a period of not more than six months after the enrollment date; and
(3) the period of the exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.
F. As used in this section, "preexisting condition exclusion" means a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for coverage for the benefits whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date, but genetic information is not included as a preexisting condition for the purposes of limiting or excluding benefits in the absence of a diagnosis of the condition related to the genetic information.
G. An insurer shall not impose a preexisting condition exclusion:
(1) in the case of an individual who, as of the last day of the thirty-day period beginning with the date of birth, is covered under creditable coverage;
(2) that excludes a child who is adopted or placed for adoption before his eighteenth birthday and who, as of the last day of the thirty-day period beginning on and following the date of the adoption or placement for adoption, is covered under creditable coverage; or
(3) that relates to or includes pregnancy as a preexisting condition.
H. The provisions of Paragraphs (1) and (2) of Subsection G of this section do not apply to any individual after the end of the first continuous sixty-three-day period during which the individual was not covered under any creditable coverage.
I. 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 prior health insurance coverage if the effective date of coverage for health insurance through the alliance is made not later than sixty-three days following the termination of the prior coverage. In that case, coverage through the alliance shall be effective from the date on which the prior coverage was terminated. This subsection does not prohibit preexisting conditions coverage in an approved health plan that is more favorable to the covered individual than that specified in this subsection.
J. An approved health plan issued to an eligible individual shall not contain any preexisting condition exclusion.
K. An individual is not eligible for coverage by the alliance under an approved health plan issued to a small employer if he:
(1) is eligible for medicare; provided, however, if an individual has health insurance coverage from an employer whose group includes twenty or more individuals, an individual eligible for medicare who continues to be employed may choose to be covered through an approved health plan;
(2) has voluntarily terminated health insurance issued through the alliance within the past twelve months unless it was due to a change in employment; or
(3) is an inmate of a public institution.
L. The alliance shall provide for an open enrollment period of sixty days from the initial offering of an approved health plan. Individuals enrolled during the open enrollment period shall not be subject to the preexisting conditions limitation.
M. If an insured covered by an approved health plan switches to another approved health plan that provides increased or additional benefits such as lower deductible or co-payment requirements, the member offering the approved health plan with increased or additional benefits may require the six-month period for preexisting conditions provided in Subsection E of this section to be satisfied prior to receipt of the additional benefits."
- 10 -